Provider Demographics
NPI:1639449994
Name:RADY CHILDREN'S HOSPITAL - SAN DIEGO
Entity Type:Organization
Organization Name:RADY CHILDREN'S HOSPITAL - SAN DIEGO
Other - Org Name:KIDSTART CENTRAL
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-966-5814
Mailing Address - Street 1:3020 CHILDRENS WAY
Mailing Address - Street 2:MC 5134
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4223
Mailing Address - Country:US
Mailing Address - Phone:858-966-5990
Mailing Address - Fax:858-966-7508
Practice Address - Street 1:3665 KEARNY VILLA RD
Practice Address - Street 2:SUITE 405
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1953
Practice Address - Country:US
Practice Address - Phone:858-966-5990
Practice Address - Fax:858-966-7508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA080000028282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren