Organization
IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP
Active
Other names
Imperial Valley Family Care Medical Group Laboratory
Organization subpart
No
Provider details
NPI number
Authorized official
VACHASPATHI PALAKODETI (PRESIDENT)
(760) 355-7730
Entity
Organization
Contact information
Practice address
516 WEST ATEN ROAD, SUITE 3, IMPERIAL, CA 92251
(760) 355-2701
(760) 355-8397
Mailing address
516 WEST ATEN ROAD, SUITE 2, IMPERIAL, CA 92251
(760) 355-7730
(760) 355-7731
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
05D0681409
CA
291U00000X
Clinical Medical Laboratory
05D0973957
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
05D0681409
CLIA #
CA
01
—
1275581894
GROUP NPI
CA
01
—
CC6635
RAILROAD GROUP #
CA
05
—
LAB81409F
—
CA
01
—
P00164275
RAIL ROAD PIN
CA
Enumeration date
04/28/2006
Last updated
04/24/2008
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