Provider Demographics
NPI:1396022000
Name:PACE CLINIC
Entity type:Organization
Organization Name:PACE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERN & TRAINEE PROGRAM COORDINATO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:COHEN
Authorized Official - Last Name:CRETCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-792-3910
Mailing Address - Street 1:2400 MOORPARK AVE STE 216B
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 MOORPARK AVE STE 216B
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2631
Practice Address - Country:US
Practice Address - Phone:408-885-5935
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization