Basic Information
| Provider Information | |||||||||
| NPI: | 1063684207 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLINICAS DE SALUD DEL PUEBLO, INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | INNERCARE - MECCA DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 852 E DANENBERG DR | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603449951 | ||||||||
| FaxNumber: | 7603445840 | ||||||||
| Practice Location | |||||||||
| Address1: | 91275 66TH AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MECCA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603960521 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2008 | ||||||||
| LastUpdateDate: | 02/18/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BELL | ||||||||
| AuthorizedOfficialFirstName: | YVONNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7603449951 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | 02/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FHC71109F | 05 | CA | MEDICAID |