Provider Demographics
NPI:1427197078
Name:SYCUAN TRIBAL GOVERNMENT
Entity Type:Organization
Organization Name:SYCUAN TRIBAL GOVERNMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BARBARA
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:619-445-0707
Mailing Address - Street 1:5442 SYCUAN RD
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019-1816
Mailing Address - Country:US
Mailing Address - Phone:619-445-0707
Mailing Address - Fax:619-445-9764
Practice Address - Street 1:5442 SYCUAN RD
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92019-1816
Practice Address - Country:US
Practice Address - Phone:619-445-0707
Practice Address - Fax:619-445-9764
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SYCUAN TRIBAL GOVERNMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-06
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1427197078Medicaid
CAZZZ50681ZOtherBLUE CROSS
CA54220ZZZ50681ZOtherBLUE SHIELD OF CALIFORNIA
CATHP70066FMedicaid