Basic Information
| Provider Information | |||||||||
| NPI: | 1609000405 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY HEALTH CENTERS OF SAN DIEGO, INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHULA VISTA FAMILY HEALTH 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: | 251 LANDIS AVE | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919102628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152500 | ||||||||
| FaxNumber: | 6199349578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2009 | ||||||||
| LastUpdateDate: | 05/07/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SAN DIEGO-JAVATE | ||||||||
| AuthorizedOfficialFirstName: | LUCY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6195152300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILY HEALTH CENTERS OF SAN DIEGO, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 550000877 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 550000877 | 01 | CA | FAMILY P.A.C.T. | OTHER |