Provider Demographics
NPI:1073939591
Name:SOUTHBAY COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:SOUTHBAY COMMUNITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BONIFFACIO
Authorized Official - Middle Name:C
Authorized Official - Last Name:ESPERANZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-500-2846
Mailing Address - Street 1:1463 E PLAZA BLVD
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-3613
Mailing Address - Country:US
Mailing Address - Phone:619-474-6900
Mailing Address - Fax:616-474-0624
Practice Address - Street 1:1463 E PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-3613
Practice Address - Country:US
Practice Address - Phone:619-474-6900
Practice Address - Fax:619-474-0624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-07
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35268207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOA352680Medicaid
CAA84752Medicare UPIN