Provider Demographics
NPI:1205159258
Name:ALLERGY & IMMUNOLOGY CLINIC OF EAST BAY
Entity type:Organization
Organization Name:ALLERGY & IMMUNOLOGY CLINIC OF EAST BAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DMITRIY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUKHOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-270-5119
Mailing Address - Street 1:111 CALLE LA MONTANA
Mailing Address - Street 2:
Mailing Address - City:MORAGA
Mailing Address - State:CA
Mailing Address - Zip Code:94556-1607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2320 WOOLSEY ST
Practice Address - Street 2:STE 314
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1973
Practice Address - Country:US
Practice Address - Phone:925-270-5113
Practice Address - Fax:925-962-9955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-04
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83416261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty