Basic Information
Provider Information | |||||||||
NPI: | 1780054379 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BAY AREA COMMUNITY HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAN JOSE BACH FAMILY COMMUNITY CLINIC, INC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 40910 FREMONT BLVD | ||||||||
Address2: |   | ||||||||
City: | FREMONT | ||||||||
State: | CA | ||||||||
PostalCode: | 945384375 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5102525880 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 40910 FREMONT BLVD | ||||||||
Address2: |   | ||||||||
City: | FREMONT | ||||||||
State: | CA | ||||||||
PostalCode: | 945384375 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5107708133 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2015 | ||||||||
LastUpdateDate: | 02/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PAGE | ||||||||
AuthorizedOfficialFirstName: | ZETTIE | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5106238926 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | BAY AREA COMMUNITY HEALTH | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |   | 261QF0400X |   | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 550003720 | 01 | CA | LICENSE # | OTHER | 1780054379 | 05 | CA |   | MEDICAID |