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General NPI Number Information
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NPI Number | 1750348033
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Entity Type | Organization
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Legal Business Name | IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP
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Dates
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Enumeration Date | 04/28/2006
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Last Update Date | 04/24/2008
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Provider Practice Location Address
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Address Line | 516 WEST ATEN ROAD SUITE 3
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City | IMPERIAL
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State | CA
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Zip | 92251
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Country | US
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Telephone | 760-355-2701
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Fax | 760-355-8397
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Provider Business Mailing Address
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Address Line | 516 WEST ATEN ROAD SUITE 2
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City | IMPERIAL
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State | CA
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Zip | 92251
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Country | US
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Telephone | 760-355-7730
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Fax | 760-355-7731
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Authorized Official
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Title or Position | PRESIDENT
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Name | VACHASPATHI PALAKODETI
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Credential |
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Telephone | 760-355-7730
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 05D0973957
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 05D0681409
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License Number State | CA
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