Provider Demographics
NPI:1184306805
Name:SPACIENDA
Entity type:Organization
Organization Name:SPACIENDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:
Authorized Official - Last Name:ABRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-389-2047
Mailing Address - Street 1:975 THERMAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-1924
Mailing Address - Country:US
Mailing Address - Phone:619-261-3434
Mailing Address - Fax:
Practice Address - Street 1:5222 BALBOA AVE STE 43
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6956
Practice Address - Country:US
Practice Address - Phone:619-389-2047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center