1144292186 NPI number — WELLBOUND OF MENLO PARK LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144292186 NPI number — WELLBOUND OF MENLO PARK LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLBOUND OF MENLO PARK LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144292186
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 SANTANA ROW
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95128-2423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-953-7800
Provider Business Mailing Address Fax Number:
650-625-6007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39510 PASEO PADRE PKWY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
FREMONT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94538-4707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-953-7800
Provider Business Practice Location Address Fax Number:
510-739-3810
Provider Enumeration Date:
02/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VINCENT
Authorized Official First Name:
BERNADETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/COO
Authorized Official Telephone Number:
650-404-3600

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CDC52514F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05D1015752 . This is a "CMS CLIA CERTIFICATE OF WAIVER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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