MEDICARE: IMPERIAL BEACH COMMUNITY CLINIC

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	261QC1500X	Community Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	40	OTHER	CA	COUNTY MEDICAL SERVICES
2	HAP11826F	OTHER	CA	FAMILY PACT
3	EAP11826F	OTHER	CA	EAPC
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	BCP11826F	OTHER	CA	CDP
6	FHC11826F	OTHER	CA	MEDI CAL
7	05D0683042	OTHER		LABORATORY CLIA NUMBER

General Provider Information

NPI Number	:	1790718351
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPERIAL BEACH COMMUNITY CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 459
Second Line	:
City	:	IMPERIAL BEACH
State	:	CA
Zip	:	91933-0459
Country	:	US
Telephone Number	:	619-429-3733
Fax Number	:	619-429-6457

Provider Business Practice Location Address
First Line	:	949 PALM AVENUE
Second Line	:
City	:	IMPERIAL BEACH
State	:	CA
Zip	:	91932-1503
Country	:	US
Telephone Number	:	619-429-3733
Fax Number	:	619-429-6457

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	CONSTANCE KIRK
Credential	:
Telephone Number	:	619-429-5387

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	05/27/2010

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1427287119 — ANNIE E SCOTT R.D.
Practice Location Address:

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1649720756 — FRANCESCA FLOYD MSN, FNP-C
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Practice Fax:

Directions to “IMPERIAL BEACH COMMUNITY CLINIC ” Practice Location

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