Provider Demographics
NPI:1649369653
Name:RADY CHILDREN'S HEALTH SERVICES-SAN DIEGO
Entity type:Organization
Organization Name:RADY CHILDREN'S HEALTH SERVICES-SAN DIEGO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KAVANAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-966-5802
Mailing Address - Street 1:3020 CHILDRENS WAY
Mailing Address - Street 2:MAILCODE 5127
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4223
Mailing Address - Country:US
Mailing Address - Phone:858-576-1700
Mailing Address - Fax:858-966-8097
Practice Address - Street 1:3020 CHILDRENS WAY
Practice Address - Street 2:MAILCODE 5127
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4223
Practice Address - Country:US
Practice Address - Phone:858-576-1700
Practice Address - Fax:858-966-8097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG98449-01OtherHEALTHY FAMILY STATE PROG
CAG93636-01Medicaid