Provider Demographics
NPI:1265661441
Name:SOUTH BAY SPORTS AND PREVENTIVE MEDICINE ASSOCIATES, INC.
Entity Type:Organization
Organization Name:SOUTH BAY SPORTS AND PREVENTIVE MEDICINE ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUARMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-293-7767
Mailing Address - Street 1:455 OCONNOR DRIVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128
Mailing Address - Country:US
Mailing Address - Phone:408-293-7767
Mailing Address - Fax:408-294-6595
Practice Address - Street 1:455 OCONNOR DRIVE
Practice Address - Street 2:SUITE 150
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128
Practice Address - Country:US
Practice Address - Phone:408-293-7767
Practice Address - Fax:408-294-6595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-08
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84807332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ04703ZMedicare PIN
CAG84956Medicare UPIN