Provider Demographics
NPI:1598907487
Name:CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.
Entity Type:Organization
Organization Name:CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.
Other - Org Name:SAN YSIDRO HEALTH PARADISE HILLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-662-4100
Mailing Address - Street 1:1601 PRECISION PARK LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-1345
Mailing Address - Country:US
Mailing Address - Phone:619-662-4100
Mailing Address - Fax:619-428-7952
Practice Address - Street 1:2400 E 8TH ST
Practice Address - Street 2:SUITE # A
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2956
Practice Address - Country:US
Practice Address - Phone:619-662-4100
Practice Address - Fax:619-205-6373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-24
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550001126261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA551004Medicare Oscar/Certification