Provider Demographics
NPI:1003902917
Name:SAN DIEGO AMERICAN INDIAN HEALTH CENTER
Entity type:Organization
Organization Name:SAN DIEGO AMERICAN INDIAN HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BULFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-234-2158
Mailing Address - Street 1:2630 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-6599
Mailing Address - Country:US
Mailing Address - Phone:619-234-2158
Mailing Address - Fax:619-234-0206
Practice Address - Street 1:2630 1ST AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-6599
Practice Address - Country:US
Practice Address - Phone:619-234-2158
Practice Address - Fax:619-234-0206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS23330104100000X
CALCS17413104100000X
CAG23820A174400000X
CAA78887207R00000X
CA20936363LF0000X
CA57514122300000X
CA582781223G0001X
CAA1079212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70019FMedicaid
CABCP70019FMedicaid
CAEAPC70019FMedicaid
CAHAP70019FMedicaid
CAW6204Medicare PIN
CA551041Medicare PIN