Provider Demographics
NPI:1700830296
Name:EAST VALLEY COMMUNITY CLINIC, INC.
Entity Type:Organization
Organization Name:EAST VALLEY COMMUNITY CLINIC, INC.
Other - Org Name:MAR MONTE COMMUNITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:RAYROZ
Authorized Official - Middle Name:
Authorized Official - Last Name:DODSON-CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-795-3607
Mailing Address - Street 1:1691 THE ALAMEDA
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-2203
Mailing Address - Country:US
Mailing Address - Phone:408-795-3600
Mailing Address - Fax:408-287-0405
Practice Address - Street 1:2470 ALVIN AVE
Practice Address - Street 2:SUITE 60
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121-1664
Practice Address - Country:US
Practice Address - Phone:408-274-7100
Practice Address - Fax:408-274-8763
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PLANNED PARENTHOOD MAR MONTE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-20
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA070000036261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR11665FMedicaid
CAHAP11665FMedicaid
CABCP11665FMedicaid
CAZZR11665FMedicaid