Provider Demographics
NPI:1912950882
Name:CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.
Entity type:Organization
Organization Name:CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:GILBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FIMBRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-205-6331
Mailing Address - Street 1:1275 30TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-3476
Mailing Address - Country:US
Mailing Address - Phone:619-662-4100
Mailing Address - Fax:619-428-7952
Practice Address - Street 1:865 3RD AVENUE
Practice Address - Street 2:SUITE #133
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910
Practice Address - Country:US
Practice Address - Phone:619-662-4100
Practice Address - Fax:619-422-0134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-02-26
Deactivation Date:2016-04-18
Deactivation Code:
Reactivation Date:2016-12-06
Provider Licenses
StateLicense IDTaxonomies
CA090000300261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70394FMedicaid
CAW5740BMedicare ID - Type Unspecified
CA551808Medicare Oscar/Certification
CA551808OtherNGS PROVIDER NUMBER