1548772007 NPI number — THE BRIDGES OF SAN DIEGO, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548772007 NPI number — THE BRIDGES OF SAN DIEGO, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE BRIDGES OF SAN DIEGO, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548772007
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3755 AVOCADO BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA MESA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91941-7301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-750-6626
Provider Business Mailing Address Fax Number:
501-679-5575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5480 BALTIMORE DR STE 211
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91942-2066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-750-6626
Provider Business Practice Location Address Fax Number:
501-679-5575
Provider Enumeration Date:
10/24/2017

Additional Information

Authorized Official

Authorized Official Last Name:
LIESCH
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
619-750-6626

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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