1083165971 NPI number — SAN DIEGO STUDENT RECOVERY

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 1083165971 NPI number — SAN DIEGO STUDENT RECOVERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN DIEGO STUDENT RECOVERY
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:
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:
1083165971
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5440 MOREHOUSE DR
Provider Second Line Business Mailing Address:
SUITE 4500
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92121-1798
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5440 MOREHOUSE DR
Provider Second Line Business Practice Location Address:
SUITE 4500
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92121-1798
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-723-1581
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2016

Additional Information

Authorized Official

Authorized Official Last Name:
HILL
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
619-723-1581

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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