1437607355 NPI number — INDIAN HEALTH CENTER OF SANTA CLARA VALLEY

Table of content: (NPI 1437607355)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437607355 NPI number — INDIAN HEALTH CENTER OF SANTA CLARA VALLEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIAN HEALTH CENTER OF SANTA CLARA VALLEY
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:
INDIAN HEALTH CENTER OF SANTA CLARA VALLEY - FOREST DENTAL
Provider Other Organization Name Type Code:
5
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:
1437607355
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1333 MERIDIAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95125-5212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-445-3400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2039 FOREST AVE STE 204B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN JOSE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95128-4815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-445-3400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SCOTT
Authorized Official First Name:
ALDON
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
408-445-3400

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  070000118 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: FHC11833F . This is a "STATE PROGRAM" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FHC11833F . This is a "MEDI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 55-1137 . This is a "MEDICARE PALMETTO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FHC11833F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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