Provider Demographics
NPI:1154670404
Name:HARRIS, TRACY L
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:L
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3914 MURPHY CANYON RD
Mailing Address - Street 2:SUITE# A226
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4491
Mailing Address - Country:US
Mailing Address - Phone:858-751-0315
Mailing Address - Fax:
Practice Address - Street 1:3914 MURPHY CANYON RD
Practice Address - Street 2:SUITE# A226
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4491
Practice Address - Country:US
Practice Address - Phone:858-751-0315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000104251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA550000104OtherDBA - AVALON HOSPICE & PALLIATIVE CARE
CAHPC01791FMedicaid
CAHPC01791FMedicaid