Basic Information
| Provider Information | |||||||||
| NPI: | 1225054414 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANTA BARBARA NEIGHBORHOOD CLINICS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WESTSIDE NEIGHBORHOOD CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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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: | 8059638880 | ||||||||
| Practice Location | |||||||||
| Address1: | 628 W MICHELTORENA ST | ||||||||
| Address2: | |||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931014131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059631546 | ||||||||
| FaxNumber: | 8059624771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 12/01/2006 | ||||||||
| NPIReactivationDate: | 02/08/2007 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FENZI | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | CAMILLO | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8056177850 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SANTA BARBARA NEIGHBORHOOD CLINICS | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 050000091 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1598942492 | 01 | CA | CPD NPI | OTHER | FHC12002G | 05 | CA | MEDICAID | 168902 | 01 | CA | CCS | OTHER | BCP12002G | 01 | CA | CDP | OTHER | FHC12002G | 01 | CHDP | OTHER | 1407033301 | 01 | CA | FAMPACT NPI | OTHER | CLN 1074 | 01 | CA | BOARD OF PHARMACY CLINIC PERMIT | OTHER | HAP12002G | 01 | CA | FP | OTHER | 05D0584453 | 01 | CA | CLIA | OTHER | CLP 303897 | 01 | CA | DHS LAB REGISTRATION NUMBER | OTHER |