Basic Information
| Provider Information | |||||||||
| NPI: | 1750348033 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP LABORATORY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 516 WEST ATEN ROAD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | IMPERIAL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603557730 | ||||||||
| FaxNumber: | 7603557731 | ||||||||
| Practice Location | |||||||||
| Address1: | 516 WEST ATEN ROAD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | IMPERIAL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603552701 | ||||||||
| FaxNumber: | 7603558397 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 04/24/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PALAKODETI | ||||||||
| AuthorizedOfficialFirstName: | VACHASPATHI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7603557730 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 05D0973957 | CA | N | Laboratories | Clinical Medical Laboratory | 291U00000X | 05D0681409 | CA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 1275581894 | 01 | CA | GROUP NPI | OTHER | LAB81409F | 05 | CA | MEDICAID | CC6635 | 01 | CA | RAILROAD GROUP # | OTHER | 05D0681409 | 01 | CA | CLIA # | OTHER | P00164275 | 01 | CA | RAIL ROAD PIN | OTHER |