Provider Demographics
NPI:1023598356
Name:SAN DIEGO RESCUE MISSION
Entity type:Organization
Organization Name:SAN DIEGO RESCUE MISSION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF PROGRAMS
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DAWSEY-RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-819-1830
Mailing Address - Street 1:120 ELM ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2602
Mailing Address - Country:US
Mailing Address - Phone:619-819-1830
Mailing Address - Fax:
Practice Address - Street 1:120 ELM ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2602
Practice Address - Country:US
Practice Address - Phone:619-819-1830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN DIEGO RESCUE MISSION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1871953604Medicaid