IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP APC

Provider Demographics

• NPI: 1275581894
• Name: IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP APC
• Entity Type: Organization
• Organization Name: IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP APC
• Authorized Official - Title/Position: PRESIDENT
• Authorized Official - First Name: VACHASPATHI
• Authorized Official - Last Name: PALAKODETI
• Authorized Official - Credentials: MD
• Authorized Official - Phone: 760-355-8300
• Mailing Address - Street 1: 516 WEST ATEN ROAD
• Mailing Address - Street 2: SUITE 2
• Mailing Address - City: IMPERIAL
• Mailing Address - State: CA
• Mailing Address - Zip Code: 92251
• Mailing Address - Country: US
• Mailing Address - Phone: 760-355-7730
• Mailing Address - Fax: 760-355-7731
• Practice Address - Street 1: 516 WEST ATEN ROAD
• Practice Address - Street 2: SUITE 2
• Practice Address - City: IMPERIAL
• Practice Address - State: CA
• Practice Address - Zip Code: 92251
• Practice Address - Country: US
• Practice Address - Phone: 760-355-7730
• Practice Address - Fax: 760-355-7731
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-05-05
• Last Update Date: 2007-10-29

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	208D00000X	Allopathic & Osteopathic Physicians	General Practice		Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
CA	GR0066318	Medicaid
CA	GR0066313	Medicaid
CA	GR0066310	Medicaid
CA	GR0066312	Medicaid
CA	CC6635	Other	RAILROAD GROUP #
CA	GR0066315	Medicaid
CA	GR0066316	Medicaid
CA	GR0066314	Medicaid
CA	GR0066310	Medicaid
CA	GR0066314	Medicaid
CA	GR0066312	Medicaid
CA	GR0066313	Medicaid
CA	WA39833C	Medicare PIN
CA	W13536C	Medicare PIN
CA	W13536A	Medicare PIN
	WA39697B	Medicare PIN
CA	WA39833F	Medicare PIN
CA	GR0066316	Medicaid
CA	GR0066315	Medicaid