Provider Demographics
NPI:1619553419
Name:SATELLITE HEALTHCARE OF OAKLAND WATERFRONT, LLC
Entity Type:Organization
Organization Name:SATELLITE HEALTHCARE OF OAKLAND WATERFRONT, LLC
Other - Org Name:SATELLITE HEALTHCARE OAKLAND WATERFRONT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:669-236-5979
Mailing Address - Street 1:300 SANTANA ROW STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2424
Mailing Address - Country:US
Mailing Address - Phone:669-236-5947
Mailing Address - Fax:650-625-6007
Practice Address - Street 1:255 2ND ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-4307
Practice Address - Country:US
Practice Address - Phone:669-236-5947
Practice Address - Fax:650-625-6007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-22
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
0322OtherBUSINESS LICENSE