Provider Demographics
NPI:1669472510
Name:SD SPORTS MEDICINE AND FAMILY HEALTH CENTER
Entity Type:Organization
Organization Name:SD SPORTS MEDICINE AND FAMILY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:619-229-3909
Mailing Address - Street 1:6699 ALVARADO RD
Mailing Address - Street 2:STE 2100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5238
Mailing Address - Country:US
Mailing Address - Phone:619-229-3909
Mailing Address - Fax:619-229-3902
Practice Address - Street 1:6699 ALVARADO RD
Practice Address - Street 2:STE 2100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5238
Practice Address - Country:US
Practice Address - Phone:619-229-3909
Practice Address - Fax:619-229-3902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0064940Medicaid
CAW12026OtherGROUP PTAN
CA0970820001Medicare NSC