Provider Demographics
NPI:1770756546
Name:POMILIA, DAISY RUTH
Entity type:Individual
Prefix:
First Name:DAISY
Middle Name:RUTH
Last Name:POMILIA
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 1:1849 K AVE
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-5908
Mailing Address - Country:US
Mailing Address - Phone:619-474-2390
Mailing Address - Fax:
Practice Address - Street 1:6154 MISSION GORGE RD
Practice Address - Street 2:120
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3493
Practice Address - Country:US
Practice Address - Phone:619-285-1718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA370069MN261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA37ALMedicaid