Provider Demographics
NPI:1205417946
Name:CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO,INC.
Entity Type:Organization
Organization Name:CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-205-6339
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:
Practice Address - Street 1:391 OXFORD ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-3114
Practice Address - Country:US
Practice Address - Phone:619-662-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)