Basic Information
| Provider Information | |||||||||
| NPI: | 1508295502 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP, APC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 516 W ATEN RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | IMPERIAL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922519805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603557730 | ||||||||
| FaxNumber: | 7603557731 | ||||||||
| Practice Location | |||||||||
| Address1: | 608 G ST | ||||||||
| Address2: | SUITE 1A | ||||||||
| City: | BRAWLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922272568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603511011 | ||||||||
| FaxNumber: | 7605450247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2013 | ||||||||
| LastUpdateDate: | 11/20/2013 | ||||||||
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| AuthorizedOfficialLastName: | PALAKODETI | ||||||||
| AuthorizedOfficialFirstName: | VACHASPATHI | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7603557730 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP, APC | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | GR0066310 | 05 | CA | MEDICAID | GR0066318 | 05 | CA | MEDICAID |