Provider Demographics
NPI:1619279361
Name:PQ OUTREACH COALITION
Entity Type:Organization
Organization Name:PQ OUTREACH COALITION
Other - Org Name:IMPACT COMMUNITY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHAIR BOARD OF DIRECTORS
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:HARMANING
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:858-206-1860
Mailing Address - Street 1:10060 CARMEL MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-3228
Mailing Address - Country:US
Mailing Address - Phone:858-206-1860
Mailing Address - Fax:858-484-8577
Practice Address - Street 1:10060 CARMEL MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-3228
Practice Address - Country:US
Practice Address - Phone:858-206-1860
Practice Address - Fax:858-484-8577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service