Centro de Salud de la Comunidad de San Ysidro, Inc.
Organization Active NPI Federally Qualified Health Center (FQHC) · San Diego, CA
NPI 1124782685 · NPPES record last updated Nov 18, 2022
Key facts
- NPI
- 1124782685
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.
- Practice address
- 1666 Precision Park LN
San Diego, CA 92173-1346 - Phone
- (619) 662-4100
- NPI assigned
- Oct 29, 2021
- Organization subpart
- No
Authorized official
- Name
- William Brian Wallace
- Title
- VP/Cfo
- Phone
- (619) 205-6339
Owners & managing parties with NPI records 1
-
Kusay Isam Arabo, O.D.
Other NPIs on the same Medicare enrollment 40
Corporate family (same tax ID) 15
Practitioners 622
-
Ahmed Mayet Abdulrahim, D.C.
-
Emad Abu-Khieran, MD
-
Susana Acevedo, MD
-
Kevin Ross Adams, DDS
-
Shruti Aggarwal, MBBS
-
Shams Alamili, MD
-
Abbas Ali, M.D
-
Aurelia Allen, NURSE PRACTITIONER
-
Miguel Alvarez-Estrada, M.D., M.B.A.
-
Ilian Alvarez, ED.D
-
Soroosh Amanat, M.D.
-
Afsaneh Amini, O.D.
-
Mandy Marie Anderson, M.D.
-
Ernestina Araiza, PSY.D.
-
Rene' Marie Arlinghaus, LCSW
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in CA
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
- Corporation · Non-profit
- Incorporated
- Feb 5, 1971 in CA
- Enrollment address
- 1666 Precision Park LN
San Diego, CA 92173-1346
All disclosed owners & managing parties 14
| Name | Role | Since | Share |
|---|---|---|---|
| Tomas Urtasun |
Corporate Director |
Apr 1, 2010 | |
| Guillermo Gomez |
Corporate Director |
Oct 20, 2012 | |
| Catalina Valencia |
Corporate Director |
Oct 28, 2017 | |
| William Wallace |
Corporate Officer |
Jan 20, 2016 | |
| Victor Nieto |
Corporate Director |
Jan 27, 1999 | |
| Reynaldo Perez |
Corporate Director |
Apr 1, 1995 | |
| Michael Dew |
Corporate Officer |
Nov 23, 2020 | |
| W-2 Managing Employee |
Nov 23, 2020 | ||
| Fred Dorsey |
Corporate Director |
Oct 21, 2016 | |
| Kusay I Arabo |
Corporate Director |
Aug 24, 2017 | |
| Gloria Ramirez |
Corporate Director |
Aug 4, 1994 | |
| Paul Romayor |
Corporate Director |
Dec 22, 2021 | |
| Macario Gutierrez |
Corporate Director |
May 20, 1975 | |
| Kevin Mattson |
Corporate Officer |
Jul 1, 2002 | |
| Margarita Navarro |
Corporate Director |
Apr 27, 1995 |
All facility ownership & control disclosures 6
| Facility | Type | Role | Since |
|---|---|---|---|
| San Ysidro Health CHC-Ocean View |
Federally qualified health center | 5% Or Greater Direct Ownership Interest | Aug 25, 2008 |
| San Ysidro Health Euclid |
Federally qualified health center | 5% Or Greater Direct Ownership Interest | Aug 25, 2009 |
| San Ysidro Health Otay |
Federally qualified health center | 5% Or Greater Direct Ownership Interest (100%) | Feb 5, 1971 |
| San Ysidro Health San Diego Pace/Senior Health Services |
Federally qualified health center | 5% Or Greater Direct Ownership Interest | Sep 1, 2014 |
| San Ysidro Health El Cajon/San Diego Pace |
Federally qualified health center | 5% Or Greater Direct Ownership Interest (100%) | Dec 1, 2015 |
| San Ysidro Health South Bay |
Federally qualified health center | 5% Or Greater Direct Ownership Interest (5%) | Jun 1, 2016 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
National Provider Directory
- Tax ID family
- Centro de Salud de la Comun
Locations
1664 Precision Park Ln
San Ysidro, CA 92173
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
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
- San Ysidro Health Precision Park
Other providers in San Diego, CA
- Centro de Salud de la Comunidad de San Ysidro Inc
- Centro de Salud de la Comunidad de San Ysidro Inc
- Centro de Salud de la Comunidad de San Ysidro Inc
- Centro de Salud de la Comunidad de San Ysidro, Inc
- Centro de Salud de la Comunidad de San Ysidro, Inc.
- Centro de Salud de la Comunidad de San Ysidro, Inc.
- Centro de Salud de la Comunidad de San Ysidro, Inc.
- Centro de Salud de la Comunidad de San Ysidro, Inc.
- Centro de Salud de la Comunidad de San Ysidro, Inc.
- Centro de Salud de la Comunidad de San Ysidro, Inc.
All providers in San Diego, CA · Federally Qualified Health Center (FQHC) in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 18, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.