MEDICARE: CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1235804139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.

Provider Business Mailing Address
First Line	:	1601 PRECISION PARK LN
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92173-1345
Country	:	US
Telephone Number	:	619-662-4100
Fax Number	:

Provider Business Practice Location Address
First Line	:	2721 WASHINGTON ST
Second Line	:
City	:	JULIAN
State	:	CA
Zip	:	92036-9233
Country	:	US
Telephone Number	:	619-662-4100
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	WILLIAM BRIAN WALLACE
Credential	:
Telephone Number	:	619-205-6339

Provider Enumeration Date	:	08/12/2021
Last Update Date	:	08/12/2021

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