Healthcare Provider Details

I. General information

NPI: 1508295502
Provider Name (Legal Business Name): IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP, APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2013
Last Update Date: 11/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 G ST SUITE 1A
BRAWLEY CA
92227-2568
US

IV. Provider business mailing address

516 W ATEN RD SUITE 2
IMPERIAL CA
92251-9805
US

V. Phone/Fax

Practice location:
  • Phone: 760-351-1011
  • Fax: 760-545-0247
Mailing address:
  • Phone: 760-355-7730
  • Fax: 760-355-7731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: VACHASPATHI PALAKODETI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 760-355-7730