Provider Demographics
NPI:1376820159
Name:IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP
Entity Type:Organization
Organization Name:IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VACHASPATHI
Authorized Official - Middle Name:
Authorized Official - Last Name:PALAKODETI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-355-7730
Mailing Address - Street 1:516 WEST ATEN ROAD SUITE 2
Mailing Address - Street 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 1:1520 SOUTH IMPERIAL AVENUE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243
Practice Address - Country:US
Practice Address - Phone:760-592-4586
Practice Address - Fax:760-545-0252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty