1306827332 NPI number — SAN DIEGO FAMILY CARE

Table of content: (NPI 1306827332)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306827332 NPI number — SAN DIEGO FAMILY CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN DIEGO FAMILY CARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MID-CITY COMMUNITY CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306827332
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4290 POLK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92105-1524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-563-0507
Provider Business Mailing Address Fax Number:
619-563-0015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4290 POLK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92105-1524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-563-0507
Provider Business Practice Location Address Fax Number:
619-563-0015
Provider Enumeration Date:
11/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FEINBERG
Authorized Official First Name:
ROBERTA
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
619-563-0507

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: HAP 11882 G . This is a "SOFP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FHC 11882 G . This is a "MEDI-CAL (FQHC)" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 80406 . This is a "HEALTHY FAMILIES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: W815 . This is a "OTHER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: EAP 11672 F . This is a "EXPANDED ACCESS TO PRIMAR" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: BCP 11882 F . This is a "BCP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com