Healthcare Provider Details

I. General information

NPI: 1538701990
Provider Name (Legal Business Name): EL CENTRO PHYSICIAN SERVICES, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2019
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1271 ROSS AVE
EL CENTRO CA
92243-4304
US

IV. Provider business mailing address

1271 ROSS AVE
EL CENTRO CA
92243-4304
US

V. Phone/Fax

Practice location:
  • Phone: 760-791-4293
  • Fax:
Mailing address:
  • Phone: 760-791-4293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES HUMPHREY
Title or Position: PRESIDENT
Credential: MD
Phone: 760-791-4293