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General NPI Number Information
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NPI Number | 1790718351
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Entity Type | Organization
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Legal Business Name | IMPERIAL BEACH COMMUNITY CLINIC
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Dates
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Enumeration Date | 07/08/2006
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Last Update Date | 05/27/2010
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Provider Practice Location Address
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Address Line | 949 PALM AVENUE
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City | IMPERIAL BEACH
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State | CA
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Zip | 91932-1503
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Country | US
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Telephone | 619-429-3733
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Fax | 619-429-6457
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Provider Business Mailing Address
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Address Line | PO BOX 459
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City | IMPERIAL BEACH
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State | CA
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Zip | 91933-0459
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Country | US
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Telephone | 619-429-3733
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Fax | 619-429-6457
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | CONSTANCE KIRK
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Credential |
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Telephone | 619-429-5387
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number |
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License Number State |
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