1912950882 NPI number — CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.

Table of content: MR. JEFFREY CHARLES MUNSON LCSW (NPI 1467492157)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912950882 NPI number — CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.
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:
Provider Other Organization Name Type Code:
6
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:
1912950882
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
04/18/2016
NPI Reactivation Date:
12/06/2016

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1275 30TH ST
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:
92154-3476
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-662-4100
Provider Business Mailing Address Fax Number:
619-428-7952

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
865 3RD AVENUE
Provider Second Line Business Practice Location Address:
SUITE #133
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-662-4100
Provider Business Practice Location Address Fax Number:
619-422-0134
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FIMBRES
Authorized Official First Name:
GILBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
619-205-6331

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  090000300 , 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: FHC70394F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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