Basic Information
| Provider Information | |||||||||
| NPI: | 1033759311 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BORREGO COMMUNITY HEALTH FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2369 | ||||||||
| Address2: | |||||||||
| City: | BORREGO SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920042369 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8881 FLETCHER PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194646434 | ||||||||
| FaxNumber: | 6194645109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2020 | ||||||||
| LastUpdateDate: | 01/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROSSELLI | ||||||||
| AuthorizedOfficialFirstName: | ANTONIO | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 6198733538 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BORREGO COMMUNITY HEALTH FOUNDATION | ||||||||
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| NPICertificationDate: | 01/14/2020 | ||||||||
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.