Provider Demographics
NPI:1326225632
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:SAN YSIDRO HEALTH CHC-OCEAN VIEW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-662-4100
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:619-428-7952
Practice Address - Street 1:3177 OCEAN VIEW BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-1432
Practice Address - Country:US
Practice Address - Phone:619-662-4100
Practice Address - Fax:619-428-7952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA090000143261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW5740OtherMEDICARE PART B PTAN
CAFHC11998GMedicaid
CAW5740OtherMEDICARE PART B PTAN