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General NPI Number Information
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NPI Number | 1952429821
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Entity Type | Organization
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Legal Business Name | CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.
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Dates
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Enumeration Date | 03/27/2007
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Last Update Date | 11/06/2019
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Provider Practice Location Address
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Address Line | 3177 OCEAN VIEW BLVD
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City | SAN DIEGO
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State | CA
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Zip | 92113-1432
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Country | US
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Telephone | 619-662-4100
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Fax | 619-205-6373
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Provider Business Mailing Address
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Address Line | 1601 PRECISION PARK LN
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City | SAN DIEGO
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State | CA
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Zip | 92173-1345
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Country | US
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Telephone | 619-205-6349
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Fax | 619-428-7952
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | KEVIN MATTSON
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Credential |
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Telephone | 619-662-4100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHY49259
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License Number State | CA
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