Provider Demographics
NPI:1508028200
Name:IMPERIAL BEACH COMMUNITY CLINIC
Entity Type:Organization
Organization Name:IMPERIAL BEACH COMMUNITY CLINIC
Other - Org Name:IMPERIAL BEACH HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-429-5387
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91933-0459
Mailing Address - Country:US
Mailing Address - Phone:619-429-5387
Mailing Address - Fax:619-429-6457
Practice Address - Street 1:949 PALM AVENUE
Practice Address - Street 2:
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-1503
Practice Address - Country:US
Practice Address - Phone:619-429-3733
Practice Address - Fax:619-429-6457
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMPERIAL BEACH COMMUNITY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW2105Medicare PIN