Provider Demographics
NPI:1184834012
Name:CABLE STREET FAMILY PRACTICE AND MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:CABLE STREET FAMILY PRACTICE AND MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NOLI
Authorized Official - Middle Name:A
Authorized Official - Last Name:CAVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-221-4490
Mailing Address - Street 1:1808 CABLE ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-3103
Mailing Address - Country:US
Mailing Address - Phone:619-221-4490
Mailing Address - Fax:619-221-4494
Practice Address - Street 1:1808 CABLE ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92107-3103
Practice Address - Country:US
Practice Address - Phone:619-221-4490
Practice Address - Fax:619-221-4494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84802261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14659OtherPTAN
CA3836332Medicaid
CA3836332Medicaid
CAS84373Medicare UPIN