Provider Demographics
NPI:1497021109
Name:BAY AREA COMMUNITY HEALTH
Entity Type:Organization
Organization Name:BAY AREA COMMUNITY HEALTH
Other - Org Name:BAY AREA COMMUNITY HEALTH - MAIN STREET VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ZETTIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:PAGE
Authorized Official - Suffix:III
Authorized Official - Credentials:MD, PHD, MBA, MSW, M
Authorized Official - Phone:510-252-6811
Mailing Address - Street 1:40910 FREMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-4375
Mailing Address - Country:US
Mailing Address - Phone:510-770-8040
Mailing Address - Fax:510-623-8926
Practice Address - Street 1:3607 MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-4390
Practice Address - Country:US
Practice Address - Phone:510-770-8040
Practice Address - Fax:510-623-8926
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAY AREA COMMUNITY HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-27
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550002016261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA550002016OtherCLINIC LICENSE
CA1497021109Medicaid