Provider Demographics
NPI:1922485952
Name:SAN JOSE FOOTHILL FAMILY COMMUNITY CLINIC, INC
Entity Type:Organization
Organization Name:SAN JOSE FOOTHILL FAMILY COMMUNITY CLINIC, INC
Other - Org Name:MONTEREY PLAZA HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SALVADOR
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVARIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-729-4240
Mailing Address - Street 1:2670 S WHITE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-2071
Mailing Address - Country:US
Mailing Address - Phone:408-729-4240
Mailing Address - Fax:866-931-7822
Practice Address - Street 1:5504 MONTEREY HWY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95138-1529
Practice Address - Country:US
Practice Address - Phone:408-729-9700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN JOSE FOOTHILL FAMILY COMMUNITY CLINIC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-28
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA551869Medicare PIN