Provider Demographics
NPI:1700186616
Name:SENIORS OF SAN DIEGO
Entity Type:Organization
Organization Name:SENIORS OF SAN DIEGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PATIENT CARE
Authorized Official - Prefix:MS
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERIALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-392-9331
Mailing Address - Street 1:5019 SURFSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-8449
Mailing Address - Country:US
Mailing Address - Phone:619-207-0057
Mailing Address - Fax:
Practice Address - Street 1:5019 SURFSIDE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-8449
Practice Address - Country:US
Practice Address - Phone:619-207-0057
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2010023464302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization