Provider Demographics
NPI:1417760364
Name:FIDARE HEALTH CO
Entity type:Organization
Organization Name:FIDARE HEALTH CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHON
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEATON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-782-0011
Mailing Address - Street 1:2358 UNIVERSITY AVE STE 371
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-2720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3434 GROVE ST
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-1812
Practice Address - Country:US
Practice Address - Phone:619-782-0011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health