Healthcare Provider Details

I. General information

NPI: 1508028200
Provider Name (Legal Business Name): IMPERIAL BEACH COMMUNITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

949 PALM AVENUE
IMPERIAL BEACH CA
91932-1503
US

IV. Provider business mailing address

PO BOX 459
IMPERIAL BEACH CA
91933-0459
US

V. Phone/Fax

Practice location:
  • Phone: 619-429-3733
  • Fax: 619-429-6457
Mailing address:
  • Phone: 619-429-5387
  • Fax: 619-429-6457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: CONSTANCE KIRK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 619-429-5387