Basic Information
| Provider Information | |||||||||
| NPI: | 1306467865 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN JOSE FOOTHILL FAMILY COMMUNITY CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2670 S WHITE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951482073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4087294290 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2060 ABORN RD STE 125 | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951211586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4087299700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2020 | ||||||||
| LastUpdateDate: | 05/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | KOZUMA | ||||||||
| AuthorizedOfficialFirstName: | NEIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | DEVELOPMENT DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4087294290 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAN JOSE FOOTHILL FAMILY COMMUNITY CLINIC, INC. | ||||||||
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| AuthorizedOfficialCredential: | JD, MPA | ||||||||
| NPICertificationDate: | 05/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.