Provider Demographics
NPI:1497975882
Name:SAN JOSE/EVERGREEN COMMUNITY COLLEGE DISTRICT
Entity Type:Organization
Organization Name:SAN JOSE/EVERGREEN COMMUNITY COLLEGE DISTRICT
Other - Org Name:EVERGREEN VALLEY COLLEGESTUDENT HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF STUDENT HEALTH SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:ASSADI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:408-274-7900
Mailing Address - Street 1:3095 YERBA BUENA RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95135-1513
Mailing Address - Country:US
Mailing Address - Phone:408-270-6480
Mailing Address - Fax:408-532-1831
Practice Address - Street 1:3095 YERBA BUENA RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95135-1513
Practice Address - Country:US
Practice Address - Phone:408-270-6480
Practice Address - Fax:408-532-1831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAEXE70004F261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEXE70004FMedicaid