MEDICARE: IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP

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	291U00000X	Clinical Medical Laboratory	05D0973957	CA
2	291U00000X	Clinical Medical Laboratory	05D0681409	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1275581894	OTHER	CA	GROUP NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	CC6635	OTHER	CA	RAILROAD GROUP #
4	05D0681409	OTHER	CA	CLIA #
5	P00164275	OTHER	CA	RAIL ROAD PIN

General Provider Information

NPI Number	:	1750348033
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP

Provider Business Mailing Address
First Line	:	516 WEST ATEN ROAD
Second Line	:	SUITE 2
City	:	IMPERIAL
State	:	CA
Zip	:	92251
Country	:	US
Telephone Number	:	760-355-7730
Fax Number	:	760-355-7731

Provider Business Practice Location Address
First Line	:	516 WEST ATEN ROAD
Second Line	:	SUITE 3
City	:	IMPERIAL
State	:	CA
Zip	:	92251
Country	:	US
Telephone Number	:	760-355-2701
Fax Number	:	760-355-8397

Authorized Official
Title or Position	:	PRESIDENT
Name	:	VACHASPATHI PALAKODETI
Credential	:
Telephone Number	:	760-355-7730

Provider Enumeration Date	:	04/28/2006
Last Update Date	:	04/24/2008

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1275581894 — IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP APC
Practice Location Address:

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1649224387 — MR. VACHASPATHI PALAKODETI MD
Practice Location Address:

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92251

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Directions to “IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP ” Practice Location

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