Basic Information
| Provider Information | |||||||||
| NPI: | 1063438232 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANTA BARBARA NEIGHBORHOOD CLINICS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EASTSIDE NEIGHBORHOOD CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 915 N MILPAS ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931032331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056177858 | ||||||||
| FaxNumber: | 8058982002 | ||||||||
| Practice Location | |||||||||
| Address1: | 915 N MILPAS ST | ||||||||
| Address2: | |||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931032331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059631641 | ||||||||
| FaxNumber: | 8059626616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FENZI | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | CAMILLO | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8056177850 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 050000113 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 050000113 | 01 | CA | COMMUNITY CLINIC LICENSE | OTHER | HAP70114G | 01 | CA | FAMPACT LEGACY NUMBER | OTHER | BCP70114G | 01 | CA | CDP PROVIDER NUMBER | OTHER | EAP70114G | 01 | CA | EAPC PROVIDER NUMBER | OTHER | CLP 303897 | 01 | CA | DHS LAB REGISTRATION NUMBER | OTHER | 168904 | 01 | CA | CCS | OTHER | 05D0584453 | 01 | CA | CLIA NUMBER | OTHER | CLN 1072 | 01 | CA | BOARD OF PHARMACY CLINIC PERMIT | OTHER | FHC70114G | 05 | CA | MEDICAID |