Provider Demographics
NPI:1942659149
Name:CIECAL RC INC
Entity Type:Organization
Organization Name:CIECAL RC INC
Other - Org Name:SOUTH BAY PRIMARY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:POLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-591-9001
Mailing Address - Street 1:769 MEDICAL CENTER CT
Mailing Address - Street 2:SUITE 303
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-6602
Mailing Address - Country:US
Mailing Address - Phone:619-591-9001
Mailing Address - Fax:619-591-9211
Practice Address - Street 1:769 MEDICAL CENTER CT
Practice Address - Street 2:SUITE 303
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6602
Practice Address - Country:US
Practice Address - Phone:619-591-9001
Practice Address - Fax:619-591-9211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-08
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80610261QP2300X
CAA76528261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care