1538223813 NPI number — FAMILY & PREVENTIVE MEDICAL CENTER OF CHULA VISTA A MEDICAL CORPORATIO

Table of content: (NPI 1538223813)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538223813 NPI number — FAMILY & PREVENTIVE MEDICAL CENTER OF CHULA VISTA A MEDICAL CORPORATIO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY & PREVENTIVE MEDICAL CENTER OF CHULA VISTA A MEDICAL CORPORATIO
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:
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:
1538223813
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1415 RIDGEBACK RD
Provider Second Line Business Mailing Address:
#4
Provider Business Mailing Address City Name:
CHULA VISTA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91910-6932
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-421-4257
Provider Business Mailing Address Fax Number:
619-421-6913

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1415 RIDGEBACK RD
Provider Second Line Business Practice Location Address:
#4
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91910-6932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-421-4257
Provider Business Practice Location Address Fax Number:
619-421-6913
Provider Enumeration Date:
12/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MALONE
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
619-421-4257

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  G46053 , 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: W14157 . This is a "MEDICARE ID-TYPE UNSPECI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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