Provider Demographics
NPI:1538293097
Name:SAN DIEGO YOUTH SERVICES
Entity Type:Organization
Organization Name:SAN DIEGO YOUTH SERVICES
Other - Org Name:BRIDGMAN HOME EPSDT
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:PHILIPS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:619-221-8600
Mailing Address - Street 1:3255 WING ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4638
Mailing Address - Country:US
Mailing Address - Phone:619-221-8600
Mailing Address - Fax:619-221-8611
Practice Address - Street 1:968 CORTE MARIA AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-2219
Practice Address - Country:US
Practice Address - Phone:619-651-8470
Practice Address - Fax:619-651-8467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA93338Medicare UPIN