Provider Demographics
NPI:1659453769
Name:VIRTUAL REALITY MEDICAL CENTER
Entity Type:Organization
Organization Name:VIRTUAL REALITY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEDERHOLD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD MD FACP
Authorized Official - Phone:858-642-0267
Mailing Address - Street 1:6160 CORNERSTONE COURT EAST
Mailing Address - Street 2:STE 155
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121
Mailing Address - Country:US
Mailing Address - Phone:858-642-0267
Mailing Address - Fax:858-642-0285
Practice Address - Street 1:6160 CORNERSTONE COURT EAST
Practice Address - Street 2:STE 155
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121
Practice Address - Country:US
Practice Address - Phone:858-642-0267
Practice Address - Fax:858-642-0285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66151261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center