Centro de Salud de la Comunidad de San Ysidro, Inc.
Organization Active NPI Federally Qualified Health Center (FQHC) · Alpine, CA
NPI 1770124315 · NPPES record last updated Nov 6, 2019
Key facts
- NPI
- 1770124315
- 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
- 1620 Alpine Blvd Ste 110
Alpine, CA 91901-1103 - Phone
- (619) 662-4100
- NPI assigned
- Oct 4, 2019
- Organization subpart
- No
Authorized official
- Name
- Kevin Mattson
- Title
- President/Ceo
- Phone
- (619) 662-4100
Owners & managing parties with NPI records 2
-
Kusay Isam Arabo, O.D.
-
Jairo Alberto Romero, M.D.
Other NPIs on the same Medicare enrollment 40
Corporate family (same tax ID) 23
Practitioners 15
-
Oscar Manuel De la Mora, M.D.
-
Hung Gi, PA-C
-
Amy Elizabeth Jennings, LCSW
-
Lesley Lara, MD
-
Bhavesh B Patel, D.O.
-
Gregory A Talavera, M.D.
-
Ashley Tapia, BS
-
Dalia Mary Thomas, MSW
-
Elsa Torres, OT
-
Jessica Rose Sanders, RN, BSN, MSN, FNP-BC
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in CA
Federally qualified health center certification: CCN 921867
- Legal name
- CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC.
- Doing business as
- SAN YSIDRO HEALTH ALPINE FAMILY MEDICINE
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- May 26, 2020
- Last certification
- May 26, 2020
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Feb 5, 1971 in CA
- Enrollment address
- 1620 Alpine Blvd
#107-111, 114, 116-119, 123, 211, 214, 227
Alpine, CA 91901-1102
All disclosed owners & managing parties 15
| Name | Role | Since | Share |
|---|---|---|---|
| Tomas Urtasun |
Corporate Officer |
Apr 1, 2010 | |
| Guillermo Gomez |
Corporate Officer |
Oct 20, 2012 | |
| Catalina Valencia |
Corporate Director |
Oct 28, 2017 | |
| William Wallace |
Corporate Officer |
Jan 20, 2016 | |
| Victor Nieto |
Corporate Officer |
Jan 27, 1999 | |
| Jairo a Romero |
Corporate Director |
Jan 27, 2023 | |
| Reynaldo Perez |
Corporate Officer |
Apr 1, 1995 | |
| Michael Dew |
Corporate Officer |
Dec 1, 2021 | |
| W-2 Managing Employee |
Dec 1, 2021 | ||
| Dave Brooke |
Corporate Director |
Sep 1, 2024 | |
| Fred Dorsey |
Corporate Director |
Oct 20, 2016 | |
| Kusay I Arabo |
Corporate Director |
Aug 24, 2017 | |
| Gloria Ramirez |
Corporate Officer |
Aug 4, 1994 | |
| Macario Gutierrez |
Corporate Officer |
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 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… |
| O20200624001258 | CA | Part a Provider - Federally Qualified Health Center (FQHC) | 6901709435 | Practice locations: Alpine, CA |
National Provider Directory
- Tax ID family
- Centro de Salud de la Comun
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
1620 Alpine Blvd Ste 110
Alpine, CA 91901-1103
Mailing address
1601 Precision Park LN
San Diego, CA 92173-1345
Phone (619) 662-4100
Other names
- San Ysidro Health Alpine Family Medicine
Other providers in Alpine, CA
- Bradley Daniel Caldwell
- Robert T. Calvert
- Nicole Michele Campos
- Lauren Cardoso
- Kathryn Carero
- Centro de Salud de la Comunidad de San Ysidro,Inc
- Arthi Chawla
- Jenny Chen
- Chase Cheney
- Amy Rose Cochran
All providers in Alpine, 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 6, 2019. 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.