Basic Information
| Provider Information | |||||||||
| NPI: | 1679654750 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLINICAS DE SALUD DEL PUEBLO, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | INNERCARE - NILAND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 852 E DANENBERG DR | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603449951 | ||||||||
| FaxNumber: | 7603445840 | ||||||||
| Practice Location | |||||||||
| Address1: | 8027 US HWY 111 | ||||||||
| Address2: | |||||||||
| City: | NILAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603590110 | ||||||||
| FaxNumber: | 7603593629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 02/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BELL | ||||||||
| AuthorizedOfficialFirstName: | YVONNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7603449951 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | 02/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 090000456 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | HAP70526F | 01 | CA | FAMILY PACT | OTHER | BCP70526F | 01 | CA | CANCE DETECTION PROGRAM | OTHER | FHC70526F | 05 | CA | MEDICAID |