Provider Demographics
NPI:1356869119
Name:SAN DIEGO SPORTS MEDICINE & ORTHOPAEDIC CENTER INC.
Entity type:Organization
Organization Name:SAN DIEGO SPORTS MEDICINE & ORTHOPAEDIC CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-229-3932
Mailing Address - Street 1:6719 ALVARADO RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5256
Mailing Address - Country:US
Mailing Address - Phone:619-229-3932
Mailing Address - Fax:619-582-2860
Practice Address - Street 1:6719 ALVARADO RD STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5256
Practice Address - Country:US
Practice Address - Phone:619-229-3932
Practice Address - Fax:619-582-2860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-31
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty