Healthcare Provider Details

I. General information

NPI: 1952364747
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: 04/11/2006
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4004 BEYER BLVD
SAN YSIDRO CA
92173-2007
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: 619-205-6373
Mailing address:
  • Phone: 619-662-4100
  • Fax: 619-428-7952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number090000140
License Number StateCA

VIII. Authorized Official

Name: KEVIN MATTSON
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 619-662-4100