Provider Demographics
NPI:1023762804
Name:ICHULL-INGYA, CALEB FANEN
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:FANEN
Last Name:ICHULL-INGYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8775 AERO DR STE 132
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1779
Mailing Address - Country:US
Mailing Address - Phone:562-414-9764
Mailing Address - Fax:
Practice Address - Street 1:8775 AERO DR STE 132
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1779
Practice Address - Country:US
Practice Address - Phone:858-609-8742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist