Provider Demographics
NPI:1215358924
Name:THE DAVIS STREET COMMUNITY CENTER INCORPORATED
Entity Type:Organization
Organization Name:THE DAVIS STREET COMMUNITY CENTER INCORPORATED
Other - Org Name:DAVIS STREET PRIMARY CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FISCAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROSALIA
Authorized Official - Middle Name:AQUINO
Authorized Official - Last Name:MCMILLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-347-4620
Mailing Address - Street 1:3081 TEGARDEN STREET
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-5720
Mailing Address - Country:US
Mailing Address - Phone:510-347-4620
Mailing Address - Fax:510-486-4486
Practice Address - Street 1:3081 TEGARDEN
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-5720
Practice Address - Country:US
Practice Address - Phone:510-347-4620
Practice Address - Fax:510-486-4486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-23
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health