NPIMap

Organization Active NPI

Family Health Centers of San Diego, Inc.

Doing business as KidCare Express III

  • Federally Qualified Health Center (FQHC)
  • San Diego, CA
National Provider Identifier
1174560585
Registry record updated Feb 20, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
550000018 Issued in CA
Legal business name
FAMILY HEALTH CENTERS OF SAN DIEGO, INC.
Doing business as
KidCare Express III
Practice address
823 Gateway Center Way
San Diego, CA 92102-4541
Phone
(619) 515-2300
Fax
(619) 237-1856
NPI assigned
Jun 2, 2006
Last updated
Feb 20, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 20, 2024

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

Authorized official

Name
Mr. Ricardo Roman
Title
Cfo
Phone
(619) 515-2300

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 550000018 CA Primary

Addresses

Primary practice location

823 Gateway Center Way
San Diego, CA 92102-4541

Mailing address

823 Gateway Center Way
San Diego, CA 92102-4541
Phone (619) 515-2300

Other identifiers 1

IdentifierTypeStateIssuer
FHC71078FMedicaidCA

Other names 1

  • KidCare Express III Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040204000923 CA Part B Supplier - Clinic/Group Practice 3476446378 Receives reassigned benefits from 1,133 practitioners
26 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Spring Valley, CA; San Diego, CA; Lemon Grove, CA; El Cajon, CA; Chula Vista, CA
O20060613000103 CA Part A Provider - Federally Qualified Health Center (FQHC) 3476446378 Practice locations: San Diego, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1174560585. Details of each certification follow.

Federally qualified health center certification: CCN 051054

Legal name
FAMILY HEALTH CENTERS OF SAN DIEGO INC
Doing business as
KID CARE EXPRESS III
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 21, 2006
Last certification
Jun 21, 2006
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
May 23, 1973 in CA
Enrollment address
823 Gateway Center Way
San Diego, CA 92102-4541
Related CCNs
551909

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs on the same Medicare enrollment 26

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

View all 26

National Provider Directory

National Provider Directory
Tax ID family
Logan Heights Family HL118 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 24

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

View all 24

Ownership & related parties

All disclosed owners & managing parties 17

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

NameRoleSinceShare
Ricardo Roman Individual Corporate OfficerCfo Sep 20, 2010
Bertha Garcia Individual Corporate DirectorBoard Member Nov 12, 1992
Mary Teresa Sessom Individual Corporate DirectorBoard Member Sep 18, 2013
Daniel Guillen Individual Corporate DirectorBoard Member Jul 24, 2013
Margarita I Carmona Individual Corporate DirectorBoard Member Aug 21, 1978
Stephanie Perez Individual Corporate DirectorBoard Member Jun 12, 1974
Venus F Thomas Individual Corporate DirectorBoard Member Mar 15, 2000
Sean Mathews Individual Corporate DirectorBoard Member Jul 24, 2013
Barbara J Carr Individual Corporate DirectorBoard Member Jun 18, 1997
Steven R Olson Individual Corporate DirectorBoard Member Aug 13, 2008
Jose R de la Garza Individual Corporate DirectorBoard Member Jul 29, 1985
Frank Espinoza Individual Corporate DirectorBoard Member Jul 24, 2013
Facika Tafara Individual W-2 Managing EmployeeMedical Director Mar 3, 2003
Wayne R Anderson Individual Corporate DirectorBoard Member Jun 20, 2007
Janice Gilmore-See Individual Corporate DirectorBoard Member Nov 18, 1998
Fran Butler-Cohen Individual Corporate OfficerPresident & Ceo Jan 21, 1986
Cesar a Solis Individual Corporate DirectorBoard Member Jun 21, 2006

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 4

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.

NPI Registry JSON

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

{
    "created_epoch": "1149206400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1708387200000",
    "number": "1174560585",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "823 GATEWAY CENTER WAY",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921024541",
            "telephone_number": "619-515-2300",
            "fax_number": "619-237-1856"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "823 GATEWAY CENTER WAY",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921024541",
            "telephone_number": "619-515-2300",
            "fax_number": "619-237-1856"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAMILY HEALTH CENTERS OF SAN DIEGO, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-02",
        "last_updated": "2024-02-20",
        "certification_date": "2024-02-20",
        "status": "A",
        "authorized_official_last_name": "ROMAN",
        "authorized_official_first_name": "RICARDO",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "619-515-2300",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "CA",
            "license": "550000018",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FHC71078F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "KidCare Express III",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in San Diego, CA

Sources for this page

Verify at the official NPI Registry.