MEDICARE: IMPERIAL COUNTY LOCAL HEALTH AUTHORITY

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	302R00000X	Health Maintenance Organization

General Provider Information

NPI Number	:	1760254973
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPERIAL COUNTY LOCAL HEALTH AUTHORITY

Provider Business Mailing Address
First Line	:	512 W ATEN RD
Second Line	:
City	:	IMPERIAL
State	:	CA
Zip	:	92251-9718
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	512 W ATEN RD
Second Line	:
City	:	IMPERIAL
State	:	CA
Zip	:	92251-9718
Country	:	US
Telephone Number	:	760-970-5034
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MARK SOUTHWORTH
Credential	:
Telephone Number	:	760-970-5034

Provider Enumeration Date	:	10/23/2023
Last Update Date	:	10/23/2023

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Directions to “IMPERIAL COUNTY LOCAL HEALTH AUTHORITY ” Practice Location

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