Provider Demographics
NPI:1639513310
Name:TELECARE AGE WISE
Entity Type:Organization
Organization Name:TELECARE AGE WISE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERSONAL SERVICE COORDINATOR II
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:MAI
Authorized Official - Suffix:
Authorized Official - Credentials:BA, SOCIOLOGY
Authorized Official - Phone:619-481-5200
Mailing Address - Street 1:6160 MISSION GORGE RD STE 108
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-3425
Mailing Address - Country:US
Mailing Address - Phone:619-481-5200
Mailing Address - Fax:
Practice Address - Street 1:6160 MISSION GORGE RD STE 108
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3425
Practice Address - Country:US
Practice Address - Phone:619-481-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management