Provider Demographics
NPI:1780054379
Name:BAY AREA COMMUNITY HEALTH
Entity type:Organization
Organization Name:BAY AREA COMMUNITY HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ZETTIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:PAGE
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:510-623-8926
Mailing Address - Street 1:40910 FREMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-4375
Mailing Address - Country:US
Mailing Address - Phone:510-252-5880
Mailing Address - Fax:
Practice Address - Street 1:40910 FREMONT BLVD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-4375
Practice Address - Country:US
Practice Address - Phone:510-770-8133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAY AREA COMMUNITY HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-25
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA550003720OtherLICENSE #
CA1780054379Medicaid