Provider Demographics
NPI:1538223813
Name:FAMILY & PREVENTIVE MEDICAL CENTER OF CHULA VISTA A MEDICAL CORPORATIO
Entity type:Organization
Organization Name:FAMILY & PREVENTIVE MEDICAL CENTER OF CHULA VISTA A MEDICAL CORPORATIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-421-4257
Mailing Address - Street 1:1415 RIDGEBACK RD
Mailing Address - Street 2:#4
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-6932
Mailing Address - Country:US
Mailing Address - Phone:619-421-4257
Mailing Address - Fax:619-421-6913
Practice Address - Street 1:1415 RIDGEBACK RD
Practice Address - Street 2:#4
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-6932
Practice Address - Country:US
Practice Address - Phone:619-421-4257
Practice Address - Fax:619-421-6913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46053207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14157OtherMEDICARE ID-TYPE UNSPECI
CAX25641Medicare UPIN