Provider Demographics
NPI:1659415131
Name:ST. VINCENT DE PAUL VILLAGE, INC
Entity Type:Organization
Organization Name:ST. VINCENT DE PAUL VILLAGE, INC
Other - Org Name:ST. VINCENT DE PAUL VILLAGE FAMILY HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-446-2194
Mailing Address - Street 1:3350 E ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-3332
Mailing Address - Country:US
Mailing Address - Phone:619-233-8500
Mailing Address - Fax:619-645-6470
Practice Address - Street 1:1501 IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-7638
Practice Address - Country:US
Practice Address - Phone:619-233-8500
Practice Address - Fax:619-645-6470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X
CA09000297261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM70389FMedicaid