Basic Information
| Provider Information | |||||||||
| NPI: | 1457967267 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAY AREA COMMUNITY HEALTH | ||||||||
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| OtherOrganizationName: | BAY AREA COMMUNITY HEALTH - MOWRY III CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40910 FREMONT BLVD | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945384375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107708040 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1860 MOWRY AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945381730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107708040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2020 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
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| AuthorizedOfficialLastName: | PAGE | ||||||||
| AuthorizedOfficialFirstName: | ZETTIE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5102526811 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAY AREA COMMUNITY HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | MD, PH.D, MBA. MSW, | ||||||||
| NPICertificationDate: | 05/07/2021 | ||||||||
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.