Healthcare Provider Details

I. General information

NPI: 1013119569
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: 06/05/2007
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1666 PRECISION PARK LN
SAN DIEGO CA
92173-1346
US

IV. Provider business mailing address

1601 PRECISION PARK LN
SAN DIEGO CA
92173-1345
US

V. Phone/Fax

Practice location:
  • Phone: 619-428-1330
  • Fax: 619-482-7952
Mailing address:
  • Phone: 619-428-1330
  • Fax: 619-482-7952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRIAN WALLACE
Title or Position: VP/CFO
Credential:
Phone: 619-662-4100