Provider Demographics
NPI:1003033234
Name:CENTRO DE SALUD DE LA COMMUNIDAD DE SAN YSIDRO, INC
Entity Type:Organization
Organization Name:CENTRO DE SALUD DE LA COMMUNIDAD DE SAN YSIDRO, INC
Other - Org Name:SAN YSIDRO HEALTH MOBILE HEALTH SERVICES 1G
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-662-4100
Mailing Address - Street 1:1601 PRECISION PARK LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-1345
Mailing Address - Country:US
Mailing Address - Phone:619-662-4100
Mailing Address - Fax:619-428-7952
Practice Address - Street 1:4004 BEYER BLVD
Practice Address - Street 2:
Practice Address - City:SAN YSIDRO
Practice Address - State:CA
Practice Address - Zip Code:92173-2007
Practice Address - Country:US
Practice Address - Phone:619-205-6331
Practice Address - Fax:619-428-7952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000116261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health