NPIMap

Organization Active NPI

Imperial Valley Family Care Medical Group, Apc

  • Rural Health Clinic/Center
  • Brawley, CA
National Provider Identifier
1508295502
Registry record updated Nov 20, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP, APC
Practice address
608 G St
Suite 1a
Brawley, CA 92227-2568
Phone
(760) 351-1011
Fax
(760) 545-0247
NPI assigned
Nov 11, 2013
Organization subpart
Yes
Parent organization
IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP, APCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 20, 2013

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

Authorized official

Name
Vachaspathi Palakodeti, M.D.NPI 1649224387
Title
President
Phone
(760) 355-7730

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X CA Primary

Addresses

Primary practice location

608 G St
Suite 1a
Brawley, CA 92227-2568

Mailing address

516 W Aten Rd
Suite 2
Imperial, CA 92251-9805
Phone (760) 355-7730

Other identifiers 2

IdentifierTypeStateIssuer
GR0066310MedicaidCA
GR0066318MedicaidCA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20140221000213 CA Part A Provider - Rural Health Clinic 0446243083 Practice locations: Brawley, CA

Rural health clinic certification: CCN 058984

Legal name
IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP A P C
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
May 8, 2015
Last certification
Jan 26, 2018
Ownership / control type
1A
Organization structure
CorporationProprietary
Incorporated
Feb 27, 1995 in CA
Enrollment address
608 G St
Ste 1a
Brawley, CA 92227-2567

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D2125367Imperial Valley Family Care Medical Group608 G St Ste 1 a, Brawley, CA 92227Certificate of waiverFeb 5, 2027

National Provider Directory

National Provider Directory
Tax ID family
Rehm Ken4 organizations share this tax ID, including this one
Part of
Rehm Ken

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

608 G St
Ste 2
Brawley, CA 92227

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
Imperial Valley Family Care Medical Group a P C Organization, Imperial, CA Created for acquisition, Corporation 5% Or Greater Direct Ownership Interest Oct 1, 1995 100%
Operational/Managerial Control Oct 1, 1995 100%
Vachaspathi Palakodeti Individual 5% Or Greater Direct Ownership Interest Mar 1, 2000 11.12%
Corporate OfficerAuthorized Jan 1, 2007
W-2 Managing EmployeeAuthorized Mar 1, 2000
Jorge F Robles Individual 5% Or Greater Direct Ownership Interest Oct 1, 1996
Patrick Wolcott Individual 5% Or Greater Direct Ownership Interest Jun 18, 2018
Mohsen El Ramah Individual 5% Or Greater Direct Ownership Interest Jan 1, 2019
Lorenzo H Suarez Individual 5% Or Greater Direct Ownership Interest Oct 1, 1995 11.12%
Elias N Moukarzel Individual 5% Or Greater Direct Ownership Interest Aug 1, 2015 11.12%
Yong Tan Individual 5% Or Greater Direct Ownership Interest Dec 1, 2014
Hussein El-Newihi Individual 5% Or Greater Direct Ownership Interest Oct 1, 1996 11.12%
Alidad M Zadeh Individual 5% Or Greater Direct Ownership Interest Mar 5, 2018
Luz Tristan Individual 5% Or Greater Direct Ownership Interest Oct 1, 2018
Jaime E Estrada Individual 5% Or Greater Direct Ownership Interest May 6, 2008 11.12%
Unnati Sampat Individual 5% Or Greater Direct Ownership Interest Jul 1, 2014

Owners & managing parties with NPI records 13

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

View all 13

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 23

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 23

NPI Registry JSON

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

{
    "created_epoch": "1384128000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1384905600000",
    "number": "1508295502",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "516 W ATEN RD",
            "address_2": "SUITE 2",
            "city": "IMPERIAL",
            "state": "CA",
            "postal_code": "922519805",
            "telephone_number": "760-355-7730",
            "fax_number": "760-355-7731"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "608 G ST",
            "address_2": "SUITE 1A",
            "city": "BRAWLEY",
            "state": "CA",
            "postal_code": "922272568",
            "telephone_number": "760-351-1011",
            "fax_number": "760-545-0247"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP, APC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP, APC",
        "enumeration_date": "2013-11-11",
        "last_updated": "2013-11-20",
        "status": "A",
        "authorized_official_last_name": "PALAKODETI",
        "authorized_official_first_name": "VACHASPATHI",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "760-355-7730",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "CA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GR0066310",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GR0066318",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Brawley, CA

Sources for this page

Verify at the official NPI Registry.