Provider Demographics
NPI:1649562422
Name:3853 ROSECRANS ST
Entity Type:Organization
Organization Name:3853 ROSECRANS ST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPT
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:R
Authorized Official - Last Name:CASTRO
Authorized Official - Suffix:
Authorized Official - Credentials:LPT
Authorized Official - Phone:692-692-8222
Mailing Address - Street 1:3853 ROSECRANS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110
Mailing Address - Country:US
Mailing Address - Phone:619-692-8222
Mailing Address - Fax:619-692-5734
Practice Address - Street 1:3853 ROSECRANS ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3115
Practice Address - Country:US
Practice Address - Phone:619-692-8222
Practice Address - Fax:619-692-5734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23671283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital