Provider Demographics
NPI:1790088219
Name:SITI MEDICAL CLINIC
Entity Type:Organization
Organization Name:SITI MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER/ MANGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KINCAID
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:619-717-8484
Mailing Address - Street 1:1951 4TH AVE #202
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1951 4TH AVE STE 202
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2374
Practice Address - Country:US
Practice Address - Phone:619-717-8484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18150364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty