Provider Demographics
NPI:1003955733
Name:SAN DIEGO SPINE AND WELLNESS CENTER
Entity Type:Organization
Organization Name:SAN DIEGO SPINE AND WELLNESS CENTER
Other - Org Name:SAN DIEGO SPINE AND WELLNESS CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SICLARE
Authorized Official - Suffix:
Authorized Official - Credentials:CCA
Authorized Official - Phone:858-676-1171
Mailing Address - Street 1:16445 BERNARDO CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2523
Mailing Address - Country:US
Mailing Address - Phone:858-676-1166
Mailing Address - Fax:858-676-1172
Practice Address - Street 1:16445 BERNARDO CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2523
Practice Address - Country:US
Practice Address - Phone:858-676-1166
Practice Address - Fax:858-676-1172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23346111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1932206083OtherINDIVIDUAL NPI
CA1003955733OtherGROUP NPI
CADC23346Medicare UPIN
CA1003955733OtherGROUP NPI