Provider Demographics
NPI:1356685101
Name:JUVENTAS INC
Entity Type:Organization
Organization Name:JUVENTAS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRINH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-888-5728
Mailing Address - Street 1:728 COLLEEN DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-4605
Mailing Address - Country:US
Mailing Address - Phone:650-888-5728
Mailing Address - Fax:
Practice Address - Street 1:728 COLLEEN DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-4605
Practice Address - Country:US
Practice Address - Phone:650-888-5728
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-17
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA193400000X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A891760Medicaid
CA00Q796540Medicaid
CA1669567079Medicare PIN
CA00Q796540Medicaid