Provider Demographics
NPI:1972005759
Name:SAN JOSE FOOTHILL FAMILY COMMUNITY CLINIC, INC.
Entity Type:Organization
Organization Name:SAN JOSE FOOTHILL FAMILY COMMUNITY CLINIC, INC.
Other - Org Name:FCHC MOMENTUM - NORTH WHITE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SALVADOR
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVARIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-729-4290
Mailing Address - Street 1:2670 S WHITE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-2073
Mailing Address - Country:US
Mailing Address - Phone:408-729-4290
Mailing Address - Fax:866-931-7822
Practice Address - Street 1:438 N WHITE RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95127-1439
Practice Address - Country:US
Practice Address - Phone:408-729-4290
Practice Address - Fax:866-931-7822
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOOTHILL HEALTH CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-07
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)