Basic Information
| Provider Information | |||||||||
| NPI: | 1598840258 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EL CENTRO REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CALEXICO OUTPATIENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1415 ROSS AVE | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922434306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603397495 | ||||||||
| FaxNumber: | 7603397389 | ||||||||
| Practice Location | |||||||||
| Address1: | 495 E BIRCH ST STE A | ||||||||
| Address2: | |||||||||
| City: | CALEXICO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922312374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603570508 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 02/07/2019 | ||||||||
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| AuthorizedOfficialLastName: | BENAVIDEZ | ||||||||
| AuthorizedOfficialFirstName: | TISHA | ||||||||
| AuthorizedOfficialMiddleName: | IRENE | ||||||||
| AuthorizedOfficialTitleorPosition: | PATIENT FINANCIAL SERVICES DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7604825334 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | RHM18536F | 05 | CA | MEDICAID |