Basic Information
| Provider Information | |||||||||
| NPI: | 1851389696 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TIBURCIO VASQUEZ HEALTH CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22331 MISSION BLVD | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945413911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106906052 | ||||||||
| FaxNumber: | 5106900703 | ||||||||
| Practice Location | |||||||||
| Address1: | 33255 9TH ST | ||||||||
| Address2: | |||||||||
| City: | UNION CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945872137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104715880 | ||||||||
| FaxNumber: | 5104719051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| AuthorizedOfficialLastName: | SCHWAB-GALINDO | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5104603855 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 140000705 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | 261Q00000X | 140000504 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QF0400X | 140000137 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 05-1103 | 01 | CA | MEDICARE FQHC | OTHER | FHC11635F | 05 | CA | MEDICAID | HAP11635F | 01 | EDS | OTHER | FHC70644F | 01 | CA | MEDICAL | OTHER | ZZZ75101Z | 01 | CA | MEDICARE | OTHER | EAP11635F | 01 | EDS | OTHER | FHC70476F | 01 | CA | MEDICAL | OTHER | CA118859 | 01 | CA | MEDICARE PTAN PART B | OTHER |