{
"Npi": {
"NPI": "1871430967",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "Y",
"ParentOrgLBN": "CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.",
"ParentOrgTIN": null,
"OrgName": "CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "1601 PRECISION PARK LN",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SAN DIEGO",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "92173-1345",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "619-662-4100",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "601 E 14TH ST STE 101",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "NATIONAL CITY",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "91950-4629",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "619-662-4100",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "04/29/2026",
"LastUpdateDate": "04/29/2026",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "WALLACE",
"AuthorizedOfficialFirstName": "WILLIAM",
"AuthorizedOfficialMiddleName": "BRIAN",
"AuthorizedOfficialTitle": "VP/CFO",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "619-662-4100",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "251T00000X",
"TaxonomyName": "PACE Provider Organization",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}