Provider Demographics
NPI:1376744649
Name:DIRECT HEALTH MEDICAL CENTER INC
Entity Type:Organization
Organization Name:DIRECT HEALTH MEDICAL CENTER INC
Other - Org Name:SAN DIEGO SPINE & REHAB INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:K
Authorized Official - Last Name:ALLAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:858-573-0550
Mailing Address - Street 1:9610 GRANITE RIDGE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2684
Mailing Address - Country:US
Mailing Address - Phone:858-573-0550
Mailing Address - Fax:858-573-0551
Practice Address - Street 1:9610 GRANITE RIDGE DR
Practice Address - Street 2:SUITE C
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2684
Practice Address - Country:US
Practice Address - Phone:858-573-0550
Practice Address - Fax:858-573-0551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP31664111N00000X, 207Q00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6382920001Medicare NSC