Basic Information
| Provider Information | |||||||||
| NPI: | 1912076662 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN MATEO COUNTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 W 39TH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944034364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505732222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 630 LAUREL ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940632977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6502613710 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 08/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | ROZZI | ||||||||
| AuthorizedOfficialFirstName: | KRIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 6505732120 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAN MATEO MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FHC80187F | 01 | CA | FQHC | OTHER |