Basic Information
| Provider Information | |||||||||
| NPI: | 1477730737 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC. | ||||||||
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| OtherOrganizationName: | SAN YSIDRO HEALTH CHILDREN'S DENTAL CENTER AT RADY CHILDREN'S HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 PRECISION PARK LN | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921731345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196624100 | ||||||||
| FaxNumber: | 6194287952 | ||||||||
| Practice Location | |||||||||
| Address1: | 8110 BIRMINGHAM WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196624100 | ||||||||
| FaxNumber: | 6192056373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2008 | ||||||||
| LastUpdateDate: | 11/06/2018 | ||||||||
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| AuthorizedOfficialLastName: | MATTSON | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 6196624100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | 550000692 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.