Provider Demographics
NPI:1750866513
Name:SAN DIEGO, SARENA
Entity Type:Individual
Prefix:
First Name:SARENA
Middle Name:
Last Name:SAN DIEGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1368
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366-2361
Mailing Address - Country:US
Mailing Address - Phone:760-572-4100
Mailing Address - Fax:
Practice Address - Street 1:401 PICACHO RD
Practice Address - Street 2:
Practice Address - City:WINTERHAVEN
Practice Address - State:CA
Practice Address - Zip Code:92283
Practice Address - Country:US
Practice Address - Phone:760-572-4100
Practice Address - Fax:760-572-4228
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS4S2E8X5374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician