Basic Information
| Provider Information | |||||||||
| NPI: | 1962483040 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN DIEGO FAMILY CARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MID-CITY COMMUNITY CLINIC-PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4305 UNIVERISTY AVE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921051690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195630507 | ||||||||
| FaxNumber: | 6195630015 | ||||||||
| Practice Location | |||||||||
| Address1: | 4305 UNIVERISTY AVE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921051690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195630507 | ||||||||
| FaxNumber: | 6195630015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FEINBERG | ||||||||
| AuthorizedOfficialFirstName: | ROBERTA | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6195630507 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | EAP11672F | 01 | CA | EXPANDED ACESS TO PRIMARY | OTHER | FHC71000G | 01 | CA | MEDI CAL FQHC | OTHER | FHC71000G | 01 | CA | CHDP | OTHER | 80406 | 01 | CA | HEALTHY FAMILIES | OTHER |