Provider Demographics
NPI:1164643862
Name:INDIAN HEALTH CENTER OF SANTA CLARA VALLEY
Entity Type:Organization
Organization Name:INDIAN HEALTH CENTER OF SANTA CLARA VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:DR
Authorized Official - First Name:ALDON
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DM
Authorized Official - Phone:408-445-3400
Mailing Address - Street 1:1333 MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-5212
Mailing Address - Country:US
Mailing Address - Phone:408-445-3400
Mailing Address - Fax:408-448-1727
Practice Address - Street 1:1333 MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-5212
Practice Address - Country:US
Practice Address - Phone:408-445-3400
Practice Address - Fax:408-448-1727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA070000118261QF0400X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC11833FMedicaid
CAG01133-01OtherDELTA DENTAL
CAFHC11833FOtherMEDICAL
CAFHC11833FOtherMEDICAL
CA05-1979Medicare ID - Type UnspecifiedUGS