Provider Demographics
NPI:1295273639
Name:MOBILE WOUND CARE-SAN DIEGO ND
Entity type:Organization
Organization Name:MOBILE WOUND CARE-SAN DIEGO ND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT- CERTIFIED
Authorized Official - Prefix:
Authorized Official - First Name:NHI
Authorized Official - Middle Name:
Authorized Official - Last Name:DAI
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:702-927-3599
Mailing Address - Street 1:1415 SANTA DIANA RD UNIT 9
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-2745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1415 SANTA DIANA RD
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91913-2745
Practice Address - Country:US
Practice Address - Phone:702-927-3599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-06
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54015363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty