MEDICARE: JUVENTAS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	193400000X	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356685101
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUVENTAS INC

Provider Business Mailing Address
First Line	:	728 COLLEEN DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95123-4605
Country	:	US
Telephone Number	:	650-888-5728
Fax Number	:

Provider Business Practice Location Address
First Line	:	728 COLLEEN DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95123-4605
Country	:	US
Telephone Number	:	650-888-5728
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. TIEN TRINH
Credential	:	MD
Telephone Number	:	650-888-5728

Provider Enumeration Date	:	11/17/2012
Last Update Date	:	11/30/2012

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Directions to “JUVENTAS INC ” Practice Location

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