Provider Demographics
NPI:1558925016
Name:BORREGO COMMUNITY HEALTH FOUNDATION
Entity Type:Organization
Organization Name:BORREGO COMMUNITY HEALTH FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIKIA
Authorized Official - Middle Name:BRAYTON
Authorized Official - Last Name:WALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-767-6641
Mailing Address - Street 1:PO BOX 2369
Mailing Address - Street 2:
Mailing Address - City:BORREGO SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92004-2369
Mailing Address - Country:US
Mailing Address - Phone:619-873-3538
Mailing Address - Fax:
Practice Address - Street 1:31739 RIVERSIDE DR STE A1
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-7818
Practice Address - Country:US
Practice Address - Phone:619-873-3538
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BORREGO COMMUNITY HEALTH FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)