Basic Information
| Provider Information | |||||||||
| NPI: | 1861409823 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EL CENTRO REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EL CENTRO COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1415 W ROSS AVE | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603397495 | ||||||||
| FaxNumber: | 7603527612 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 W ROSS AVE | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603397495 | ||||||||
| FaxNumber: | 7603527612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 02/07/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENAVIDEZ | ||||||||
| AuthorizedOfficialFirstName: | TISHA | ||||||||
| AuthorizedOfficialMiddleName: | IRENE | ||||||||
| AuthorizedOfficialTitleorPosition: | PATIENT FINANCIAL SERVICES DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7604825334 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | ZZT30045F | 05 | CA | MEDICAID | ZZZC1303Z | 01 | BLUE SHIELD | OTHER | 050045 | 01 | BLUE CROSS | OTHER | ZZT40045F | 05 | CA | MEDICAID |