Provider Demographics
NPI:1386987915
Name:COMMUNITY ELDERCARE SAN DIEGO
Entity type:Organization
Organization Name:COMMUNITY ELDERCARE SAN DIEGO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MARKETING DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:GOIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-677-3800
Mailing Address - Street 1:111 ELM ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2692
Mailing Address - Country:US
Mailing Address - Phone:619-677-3800
Mailing Address - Fax:619-781-8186
Practice Address - Street 1:111 ELM ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2692
Practice Address - Country:US
Practice Address - Phone:619-677-3800
Practice Address - Fax:619-781-8186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-02
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550001964261QC1500X
CA305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA057Medicaid
CAH5629Medicare PIN