Healthcare Provider Details

I. General information

NPI: 1366053167
Provider Name (Legal Business Name): CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2020
Last Update Date: 09/23/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 H ST STE 2080
CHULA VISTA CA
91910-5558
US

IV. Provider business mailing address

1601 PRECISION PARK LN
SAN DIEGO CA
92173-1345
US

V. Phone/Fax

Practice location:
  • Phone: 619-662-4100
  • Fax:
Mailing address:
  • Phone: 619-662-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM BRIAN WALLACE
Title or Position: VP/CFO
Credential:
Phone: 619-205-6339