Provider Demographics
NPI:1336332725
Name:FAMILY HEALTH CENTERS OF SAN DIEGO, INC.
Entity Type:Organization
Organization Name:FAMILY HEALTH CENTERS OF SAN DIEGO, INC.
Other - Org Name:CCS/GHPP DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-515-2300
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-515-2300
Mailing Address - Fax:619-237-1856
Practice Address - Street 1:1809 NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-2113
Practice Address - Country:US
Practice Address - Phone:619-515-2300
Practice Address - Fax:619-234-2447
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY HEALTH CENTERS OF SAN DIEGO INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA090000113261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACGP169666Medicaid