Basic Information
| Provider Information | |||||||||
| NPI: | 1306827332 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN DIEGO FAMILY CARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MID-CITY COMMUNITY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4290 POLK AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921051524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195630507 | ||||||||
| FaxNumber: | 6195630015 | ||||||||
| Practice Location | |||||||||
| Address1: | 4290 POLK AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921051524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195630507 | ||||||||
| FaxNumber: | 6195630015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 07/23/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FEINBERG | ||||||||
| AuthorizedOfficialFirstName: | ROBERTA | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6195630507 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAN DIEGO FAMILY CARE | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | HAP 11882 G | 01 | CA | SOFP | OTHER | FHC 11882 G | 01 | CA | MEDI-CAL (FQHC) | OTHER | 80406 | 01 | CA | HEALTHY FAMILIES | OTHER | W815 | 01 | CA | OTHER | OTHER | EAP 11672 F | 01 | CA | EXPANDED ACCESS TO PRIMAR | OTHER | BCP 11882 F | 01 | CA | BCP | OTHER |