1720315161 NPI number — BAY AREA SPORTS CLINIC

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 1720315161 NPI number — BAY AREA SPORTS CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAY AREA SPORTS CLINIC
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:
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:
1720315161
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1800 SULLIVAN AVE
Provider Second Line Business Mailing Address:
SUITE 402
Provider Business Mailing Address City Name:
DALY CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94015-2228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-992-7700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 S SAN MATEO DR
Provider Second Line Business Practice Location Address:
SUITE 470
Provider Business Practice Location Address City Name:
SAN MATEO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94401-3857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-348-5400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/05/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SCIARONI
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
650-992-7700

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  FNP 38941 , 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)