Provider Demographics
NPI:1487171096
Name:SAN DIEGO VAMC
Entity type:Organization
Organization Name:SAN DIEGO VAMC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NPI TEAM MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-382-2579
Mailing Address - Street 1:PO BOX 94416
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-4416
Mailing Address - Country:US
Mailing Address - Phone:702-341-3020
Mailing Address - Fax:
Practice Address - Street 1:2121 SAN DIEGO AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2928
Practice Address - Country:US
Practice Address - Phone:702-341-3020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-24
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility