Provider Demographics
NPI:1164671749
Name:FAMILY HEALTH CENTERS OF SAN DIEGO, INC.
Entity Type:Organization
Organization Name:FAMILY HEALTH CENTERS OF SAN DIEGO, INC.
Other - Org Name:HEALTHY DEVELOPMENT SERVICES CENTER-CENTRAL REGION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-515-2300
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-515-2300
Mailing Address - Fax:619-237-1856
Practice Address - Street 1:2044 1ST AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2089
Practice Address - Country:US
Practice Address - Phone:619-515-2355
Practice Address - Fax:619-232-7011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-18
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X
CA090000113261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC11890FMedicaid
CAFHC11890FMedicaid
CA051803Medicare Oscar/Certification