Basic Information
| Provider Information | |||||||||
| NPI: | 1518364165 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI CITY PRIMARY CARE MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1926 VIA CENTRE DRIVE | ||||||||
| Address2: | |||||||||
| City: | VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609407000 | ||||||||
| FaxNumber: | 7609400042 | ||||||||
| Practice Location | |||||||||
| Address1: | 1926 VIA CENTRE DRIVE | ||||||||
| Address2: | |||||||||
| City: | VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609407000 | ||||||||
| FaxNumber: | 7609400042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2014 | ||||||||
| LastUpdateDate: | 01/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | DOLPHIN | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7609407000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
No ID Information.