Provider Demographics
NPI:1417026758
Name:SOUTHERN INDIAN HEALTH COUNCIL
Entity type:Organization
Organization Name:SOUTHERN INDIAN HEALTH COUNCIL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:619-445-1188
Mailing Address - Street 1:36350 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:CAMPO
Mailing Address - State:CA
Mailing Address - Zip Code:91906-2715
Mailing Address - Country:US
Mailing Address - Phone:619-478-2225
Mailing Address - Fax:619-478-2323
Practice Address - Street 1:36350 CHURCH RD
Practice Address - Street 2:
Practice Address - City:CAMPO
Practice Address - State:CA
Practice Address - Zip Code:91906-2715
Practice Address - Country:US
Practice Address - Phone:619-478-2225
Practice Address - Fax:619-478-2323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHE43448332800000X
333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2113505OtherPK
CAPHA434480Medicaid