Basic Information
| Provider Information | |||||||||
| NPI: | 1922485952 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN JOSE FOOTHILL FAMILY COMMUNITY CLINIC, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MONTEREY PLAZA HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2670 S WHITE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951482071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4087294240 | ||||||||
| FaxNumber: | 8669317822 | ||||||||
| Practice Location | |||||||||
| Address1: | 5504 MONTEREY HWY | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951381529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4087299700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2015 | ||||||||
| LastUpdateDate: | 04/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | CHAVARIN | ||||||||
| AuthorizedOfficialFirstName: | SALVADOR | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4087294240 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAN JOSE FOOTHILL FAMILY COMMUNITY CLINIC, INC | ||||||||
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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) |
No ID Information.