=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396627865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2025
-----------------------------------------------------
Last Update Date | 10/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 EAST 14TH STREET SUITE 201
-----------------------------------------------------
City | NATIONAL CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-662-4100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601 PRECISION PARK LN
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92173-1345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-662-4100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP/CFO
-----------------------------------------------------
Name | WILLIAM BRIAN WALLACE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 619-662-4100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------