Provider Demographics
NPI:1508295502
Name:IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP, APC
Entity Type:Organization
Organization Name:IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP, APC
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 W ATEN RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-9805
Mailing Address - Country:US
Mailing Address - Phone:760-355-7730
Mailing Address - Fax:760-355-7731
Practice Address - Street 1:608 G ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-2568
Practice Address - Country:US
Practice Address - Phone:760-351-1011
Practice Address - Fax:760-545-0247
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP, APC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-11
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0066310Medicaid
CAGR0066318Medicaid
CAW13536CMedicare PIN