Provider Demographics
NPI:1750112587
Name:IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP, APC
Entity type:Organization
Organization Name:IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP, APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:VACHASPATHI
Authorized Official - Middle Name:
Authorized Official - Last Name:PALAKODETI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-355-8300
Mailing Address - Street 1:516 WEST ATEN ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-9805
Mailing Address - Country:US
Mailing Address - Phone:760-355-7730
Mailing Address - Fax:760-355-7731
Practice Address - Street 1:516 WEST ATEN ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251-9805
Practice Address - Country:US
Practice Address - Phone:760-355-8300
Practice Address - Fax:760-545-0240
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP APC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-13
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC3500XNursing Service ProvidersRegistered NurseCardiac RehabilitationGroup - Single Specialty