MEDICARE: CABLE STREET FAMILY PRACTICE AND MEDICAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	G84802	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	W14659	OTHER	CA	PTAN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184834012
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CABLE STREET FAMILY PRACTICE AND MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	1808 CABLE ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-3103
Country	:	US
Telephone Number	:	619-221-4490
Fax Number	:	619-221-4494

Provider Business Practice Location Address
First Line	:	1808 CABLE ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-3103
Country	:	US
Telephone Number	:	619-221-4490
Fax Number	:	619-221-4494

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	MR. NOLI A CAVA
Credential	:	M.D.
Telephone Number	:	619-221-4490

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	12/21/2015

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