Provider Demographics
NPI:1306827332
Name:SAN DIEGO FAMILY CARE
Entity Type:Organization
Organization Name:SAN DIEGO FAMILY CARE
Other - Org Name:MID-CITY COMMUNITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FEINBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:619-563-0507
Mailing Address - Street 1:4290 POLK AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-1524
Mailing Address - Country:US
Mailing Address - Phone:619-563-0507
Mailing Address - Fax:619-563-0015
Practice Address - Street 1:4290 POLK AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1524
Practice Address - Country:US
Practice Address - Phone:619-563-0507
Practice Address - Fax:619-563-0015
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN DIEGO FAMILY CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-08
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHAP 11882 GOtherSOFP
CAFHC 11882 GOtherMEDI-CAL (FQHC)
CA80406OtherHEALTHY FAMILIES
CAW815OtherOTHER
CAEAP 11672 FOtherEXPANDED ACCESS TO PRIMAR
CABCP 11882 FOtherBCP
CA051875 (UGS)Medicare ID - Type Unspecified