1417229022 NPI number — WELLBOUND OF MENLO PARK LLC

Table of content: (NPI 1417229022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417229022 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:
1417229022
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:
650-550-3600
Provider Business Mailing Address Fax Number:
650-625-6007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 JUNIPERO SERRA BLVD
Provider Second Line Business Practice Location Address:
SUITE 535
Provider Business Practice Location Address City Name:
DALY CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94014-3891
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-550-3600
Provider Business Practice Location Address Fax Number:
650-991-3125
Provider Enumeration Date:
01/30/2012

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: 1417229022 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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