Healthcare Provider Details

I. General information

NPI: 1376184911
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: 10/04/2019
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 TOWN CENTER PKWY
SANTEE CA
92071-5801
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:
Mailing address:
  • Phone: 619-662-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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