Healthcare Provider Details

I. General information

NPI: 1659415131
Provider Name (Legal Business Name): ST. VINCENT DE PAUL VILLAGE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 IMPERIAL AVE
SAN DIEGO CA
92101-7638
US

IV. Provider business mailing address

3350 E ST
SAN DIEGO CA
92102-3332
US

V. Phone/Fax

Practice location:
  • Phone: 619-233-8500
  • Fax: 619-645-6470
Mailing address:
  • Phone: 619-233-8500
  • Fax: 619-645-6470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number09000297
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MS. MELINDA MALLIE
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 619-446-2194