1790863991 NPI number — COUNTY OF SANTA CLARA

Table of content: (NPI 1790863991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790863991 NPI number — COUNTY OF SANTA CLARA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF SANTA CLARA
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:
1790863991
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
751 S BASCOM AVE
Provider Second Line Business Mailing Address:
BUILDING W
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95128-2604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-885-2300
Provider Business Mailing Address Fax Number:
408-885-5822

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 TULLY RD
Provider Second Line Business Practice Location Address:
VHC AT TULLY PHARMACY
Provider Business Practice Location Address City Name:
SAN JOSE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95111-1917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-817-1360
Provider Business Practice Location Address Fax Number:
408-817-1367
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BANUELOS
Authorized Official First Name:
ALFONSO
Authorized Official Middle Name:
F
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
408-885-4001

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PHE30090 , 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: PHB300900 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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