Basic Information
| Provider Information | |||||||||
| NPI: | 1720405491 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TIBURCIO VASQUEZ HEALTH CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAN LEANDRO MOBILE VAN | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22331 MISSION BLVD | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945413911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106906052 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16110 E 14TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN LEANDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945783002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104715907 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2014 | ||||||||
| LastUpdateDate: | 04/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | SCHWAB-GALINDO | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5104603855 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.