Provider Demographics
NPI:1114182649
Name:PALO ALTO MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:PALO ALTO MEDICAL FOUNDATION
Other - Org Name:SUTTER SANT CRUZ MAIN 4TH FLOOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-625-2990
Mailing Address - Street 1:5810 NANCY RIDGE DR
Mailing Address - Street 2:100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-2834
Mailing Address - Country:US
Mailing Address - Phone:858-625-2990
Mailing Address - Fax:
Practice Address - Street 1:2025 SOQUEL AVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-1323
Practice Address - Country:US
Practice Address - Phone:831-458-5610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDVANTX, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-24
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84273332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site