Provider Demographics
NPI:1427216308
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:HUMAN RESOURCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:E
Authorized Official - Last Name:EDMO
Authorized Official - Suffix:
Authorized Official - Credentials:
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:408-448-1041
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:408-448-1041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-28
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA070000118261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHAP11833FOtherFAMILY PACT PROGRAM