Provider Demographics
NPI:1063658029
Name:SAN JOSE FOOTHILL FAMILY COMMUNITY CLINIC, INC.
Entity Type:Organization
Organization Name:SAN JOSE FOOTHILL FAMILY COMMUNITY CLINIC, INC.
Other - Org Name:FOOTHILL COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SALVADOR
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVARIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-729-4290
Mailing Address - Street 1:2670 SOUTH WHITE ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-2071
Mailing Address - Country:US
Mailing Address - Phone:408-729-4290
Mailing Address - Fax:866-931-7822
Practice Address - Street 1:2880 STORY ROAD
Practice Address - Street 2:SUITE 10
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95127-3942
Practice Address - Country:US
Practice Address - Phone:408-755-3920
Practice Address - Fax:866-931-7822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA070000436261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70736FMedicaid