Basic Information
| Provider Information | |||||||||
| NPI: | 1497204234 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY HEALTH CENTERS OF SAN DIEGO, INC. | ||||||||
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| OtherOrganizationName: | GROSSMONT FAMILY COUNSELING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 823 GATEWAY CENTER WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152300 | ||||||||
| FaxNumber: | 6192371856 | ||||||||
| Practice Location | |||||||||
| Address1: | 8851 CENTER DR | ||||||||
| Address2: | STE 312 | ||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152383 | ||||||||
| FaxNumber: | 6192690883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2016 | ||||||||
| LastUpdateDate: | 10/11/2016 | ||||||||
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| AuthorizedOfficialLastName: | ROMAN | ||||||||
| AuthorizedOfficialFirstName: | RICARDO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6199064603 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.