NPIMap

Organization Active NPI

Centro de Salud de la Comunidad de San Ysidro Inc

Doing business as San Ysidro Health Senior Dental Center

  • Federally Qualified Health Center (FQHC)
  • San Diego, CA
National Provider Identifier
1457033813
Registry record updated Oct 6, 2023
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 Senior Dental Center
Practice address
1525 Fourth Ave, 2ND Floor
San Diego, CA 92101-3107
Phone
(619) 662-4100
NPI assigned
Aug 4, 2023
Last updated
Oct 6, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 6, 2023

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

Authorized official

Name
Kevin Mattson
Title
President/Ceo
Phone
(619) 662-4100

Specialties & licenses 1

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

Addresses

Primary practice location

1525 Fourth Ave, 2ND Floor
San Diego, CA 92101-3107

Mailing address

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

Other names 1

  • San Ysidro Health Senior Dental Center 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
This NPI is an additional NPI on the enrollment
Practice locations: National City, CA; San Diego, CA; San Ysidro, CA; Santee, CA; Vista, CA; Alpine, CA; Campo, CA; Chula Vista, CA…
O20240514003996 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 1457033813. Details of each certification follow.

Federally qualified health center certification: CCN A01860

Legal name
CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.
Doing business as
SAN YSIDRO HEALTH SENIOR DENTAL CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 10, 2024
Last certification
May 10, 2024
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Feb 5, 1971 in CA
Enrollment address
1525 4TH Ave
FL 2
San Diego, CA 92101-3107

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 24

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

View all 24

Locations

1620 Alpine Blvd
#107111
Alpine, CA 91901

1061 Tierra del Rey
Ste 303305
Chula Vista, CA 91910

1061 Tierra del Rey
Ste 304
Chula Vista, CA 91910

340 Fourth Ave
Ste 7
Chula Vista, CA 91910
Phone (619) 428-1330

436 S Magnolia Ave
#101201
El Cajon, CA 92020
Phone (619) 401-7410

875 El Cajon Blvd
El Cajon, CA 92020
Phone (619) 205-1950

2 N Euclid Ave
Ste C
National City, CA 91950
Phone (619) 205-6363

1525 4th Ave
San Diego, CA 92101
Phone (619) 795-1301

1525 4th Ave
Fl 2
San Diego, CA 92101
Phone (616) 662-4100

286 Euclid Ave
Ste 308
San Diego, CA 92114

3364 Beyer Blvd
Ste 102
San Ysidro, CA 92173
Phone (702) 617-1227

Ownership & related parties

All disclosed owners & managing parties 13

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, 1994
Michael Dew Individual Corporate OfficerManaged Care Director Dec 1, 2021
W-2 Managing EmployeeManaged Care Director Dec 1, 2021
Fred Dorsey Individual Corporate DirectorBoard Member Oct 20, 2016
Kusay I Arabo Individual Corporate DirectorBoard Member Aug 24, 2017
Gloria Ramirez Individual Corporate DirectorBoard Member Aug 4, 1994
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 30, 1997

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 587

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 587

NPI Registry JSON

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

{
    "created_epoch": "1691107200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1696550400000",
    "number": "1457033813",
    "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": "1525 FOURTH AVE, 2ND FLOOR",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921013107",
            "telephone_number": "619-662-4100"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-08-04",
        "last_updated": "2023-10-06",
        "certification_date": "2023-10-06",
        "status": "A",
        "authorized_official_last_name": "MATTSON",
        "authorized_official_first_name": "KEVIN",
        "authorized_official_title_or_position": "PRESIDENT/CEO",
        "authorized_official_telephone_number": "619-662-4100"
    },
    "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 Senior Dental Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "San Ysidro Health Senior Dental Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in San Diego, CA

Sources for this page

Verify at the official NPI Registry.