NPIMap

Organization Active NPI

Centro de Salud de la Comunidad de San Ysidro, Inc.

Doing business as San Ysidro Health Precision Park

  • Federally Qualified Health Center (FQHC)
  • San Diego, CA
National Provider Identifier
1124782685
Registry record updated Nov 18, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.
Doing business as
San Ysidro Health Precision Park
Practice address
1666 Precision Park LN
San Diego, CA 92173-1346
Phone
(619) 662-4100
NPI assigned
Oct 29, 2021
Last updated
Nov 18, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 18, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
William Brian Wallace
Title
VP/Cfo
Phone
(619) 205-6339

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

1666 Precision Park LN
San Diego, CA 92173-1346

Mailing address

1601 Precision Park LN
San Diego, CA 92173-1345
Phone (619) 662-4100

Other names 1

  • San Ysidro Health Precision Park Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040130000711 CA Part B Supplier - Clinic/Group Practice 6901709435 Receives reassigned benefits from 611 practitioners
41 other NPIs on this enrollment
Practice locations: National City, CA; San Diego, CA; San Ysidro, CA; Santee, CA; Vista, CA; Alpine, CA; Campo, CA; Chula Vista, CA…
O20230105000649 CA Part A Provider - Federally Qualified Health Center (FQHC) 6901709435 Practice locations: San Diego, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124782685. Details of each certification follow.

Federally qualified health center certification: CCN A01139

Legal name
CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.
Doing business as
SAN YSIDRO HEALTH PRECISION PARK
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 6, 2022
Last certification
Dec 6, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Feb 5, 1971 in CA
Enrollment address
1666 Precision Park LN
San Diego, CA 92173-1346

Other NPIs on the same Medicare enrollment 40

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 40

National Provider Directory

National Provider Directory
Tax ID family
San Ysidro Health Cente52 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 15

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 15

Locations

1664 Precision Park Ln
San Ysidro, CA 92173

Ownership & related parties

All disclosed owners & managing parties 14

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Tomas Urtasun Individual Corporate DirectorBoard Member Apr 1, 2010
Guillermo Gomez Individual Corporate DirectorBoard Member Oct 20, 2012
Catalina Valencia Individual Corporate DirectorBoard Member Oct 28, 2017
William Wallace Individual Corporate OfficerVP/Cfo Jan 20, 2016
Victor Nieto Individual Corporate DirectorBoard Member Jan 27, 1999
Reynaldo Perez Individual Corporate DirectorBoard Member Apr 1, 1995
Michael Dew Individual Corporate OfficerDirector of Managed Care Operations Nov 23, 2020
W-2 Managing EmployeeDirector of Managed Care Operations Nov 23, 2020
Fred Dorsey Individual Corporate DirectorBoard Member Oct 21, 2016
Kusay I Arabo Individual Corporate DirectorBoard Member Aug 24, 2017
Gloria Ramirez Individual Corporate DirectorBoard Member Aug 4, 1994
Paul Romayor Individual Corporate DirectorBoard Member Dec 22, 2021
Macario Gutierrez Individual Corporate DirectorBoard Member May 20, 1975
Kevin Mattson Individual Corporate OfficerPresident/Ceo Jul 1, 2002
Margarita Navarro Individual Corporate DirectorBoard Member Apr 27, 1995

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 6

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
San Ysidro Health CHC-Ocean ViewSan Diego, CA, CCN 551920 Federally qualified health center 5% Or Greater Direct Ownership Interest Aug 25, 2008
San Ysidro Health EuclidSan Diego, CA, CCN 551922 Federally qualified health center 5% Or Greater Direct Ownership Interest Aug 25, 2009
San Ysidro Health OtayChula Vista, CA, CCN 551966 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Feb 5, 1971
San Ysidro Health San Diego Pace/Senior Health ServicesSan Ysidro, CA, CCN 751102 Federally qualified health center 5% Or Greater Direct Ownership Interest Sep 1, 2014
San Ysidro Health El Cajon/San Diego PaceEl Cajon, CA, CCN 751822 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Dec 1, 2015
San Ysidro Health South BayNational City, CA, CCN 751950 Federally qualified health center 5% Or Greater Direct Ownership Interest (5%) Jun 1, 2016

Practitioners & affiliated clinicians

Practitioners 622

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 622

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1635465600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1668729600000",
    "number": "1124782685",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1601 PRECISION PARK LN",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921731345",
            "telephone_number": "619-662-4100"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1666 PRECISION PARK LN",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921731346",
            "telephone_number": "619-662-4100"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-10-29",
        "last_updated": "2022-11-18",
        "certification_date": "2022-11-18",
        "status": "A",
        "authorized_official_last_name": "WALLACE",
        "authorized_official_first_name": "WILLIAM",
        "authorized_official_middle_name": "BRIAN",
        "authorized_official_title_or_position": "VP/CFO",
        "authorized_official_telephone_number": "619-205-6339"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "San Ysidro Health Precision Park",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in San Diego, CA

Sources for this page

Verify at the official NPI Registry.