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3356 2nd Ave Ste G San Diego CA 92103-5636 | |
| (858) 717-0164 | |
| (888) 425-0508 |
| Full Name | |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 3356 2nd Ave Ste G, San Diego, California |
| Authorized Official Name and Position | La Tanya Wallace (PRESIDENT) |
| Authorized Official Contact | 6193987473 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
6921 Sperry Ct San Diego CA 92111-7030 Ph: (619) 398-7473 | 3356 2nd Ave Ste G San Diego CA 92103-5636 Ph: (858) 717-0164 |
| NPI Number | 1659978328 |
|---|---|
| Provider Enumeration Date | 10/06/2020 |
| Last Update Date | 01/28/2024 |
| Certification Date | 01/28/2024 |
| Medicare PECOS PAC ID | 3779024393 |
|---|---|
| Medicare Enrollment ID | O20240924000564 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1659978328 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084P0800X | Psychiatry & Neurology - Psychiatry | (* (Not Available)) | Primary |
| Provider Name | La Tanya Wallace |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1841453487 PECOS PAC ID: 7416253075 Enrollment ID: I20240924000635 |
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