Basic Information
| Provider Information | |||||||||
| NPI: | 1780861005 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NATIONAL MEDICAL ASSOCIATION COMPREHENSIVE HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NMA COMPREHENSIVE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 446 26TH ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921023026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192313200 | ||||||||
| FaxNumber: | 6192313212 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 ELM ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921012602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192354211 | ||||||||
| FaxNumber: | 6192354517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2008 | ||||||||
| LastUpdateDate: | 07/02/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OWENS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO & CMO | ||||||||
| AuthorizedOfficialTelephone: | 6192313200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD, MPH, FACPE, CPE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | 090000618 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QF0400X | 090000618 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | BCP70794F | 01 | CA | MEDI-CAL | OTHER |