MEDICARE: CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, 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	251T00000X	PACE Provider Organization

General Provider Information

NPI Number	:	1265843122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.

Provider Business Mailing Address
First Line	:	8080 DAGGET ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-2333
Country	:	US
Telephone Number	:	619-662-4100
Fax Number	:	619-428-7952

Provider Business Practice Location Address
First Line	:	3364 BEYER BLVD
Second Line	:	SUITE #102 & #103
City	:	SAN YSIDRO
State	:	CA
Zip	:	92173-1322
Country	:	US
Telephone Number	:	619-662-4100
Fax Number	:	619-600-4867

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	KEVIN MATTSON
Credential	:
Telephone Number	:	619-662-4100

Provider Enumeration Date	:	05/14/2014
Last Update Date	:	01/27/2026

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