Provider Demographics
NPI:1841482841
Name:BRANCH MEDICAL CLINIC EL CENTRO
Entity type:Organization
Organization Name:BRANCH MEDICAL CLINIC EL CENTRO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NAVY MEDICINE UBO PROGRAM MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CONDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-401-3643
Mailing Address - Street 1:34520 BOB WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-2098
Mailing Address - Country:US
Mailing Address - Phone:619-532-6636
Mailing Address - Fax:619-532-6645
Practice Address - Street 1:NAVAL BRANCH HEALTH CLINIC
Practice Address - Street 2:NAVAL AIR FACILITY BLDG 523
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243
Practice Address - Country:US
Practice Address - Phone:760-339-2674
Practice Address - Fax:760-339-2661
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAVAL MEDICAL CENTER SAN DIEGO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05-20862OtherNCPDP
CA05022FOtherMEDICARE
CAHSP63228FMedicaid
CAZZT23228FMedicaid
CAZZT23228FMedicaid
CAAN1348463OtherDEA