Provider Demographics
NPI:1750348033
Name:IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP
Entity type:Organization
Organization Name:IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VACHASPATHI
Authorized Official - Middle Name:
Authorized Official - Last Name:PALAKODETI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-355-7730
Mailing Address - Street 1:516 WEST ATEN ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251
Mailing Address - Country:US
Mailing Address - Phone:760-355-7730
Mailing Address - Fax:760-355-7731
Practice Address - Street 1:516 WEST ATEN ROAD
Practice Address - Street 2:SUITE 3
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251
Practice Address - Country:US
Practice Address - Phone:760-355-2701
Practice Address - Fax:760-355-8397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D0973957291U00000X
CA05D0681409291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1275581894OtherGROUP NPI
CALAB81409FMedicaid
CACC6635OtherRAILROAD GROUP #
CA05D0681409OtherCLIA #
CAP00164275OtherRAIL ROAD PIN
CA05D0973957Medicare PIN
CACC6635OtherRAILROAD GROUP #
CA05D0681409Medicare Oscar/Certification