MEDICARE: BONLAVIE HOSPICE, INC. - SAN JOSE

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	251G00000X	Community Based Hospice Care Agency

General Provider Information

NPI Number	:	1811504095
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BONLAVIE HOSPICE, INC. - SAN JOSE

Provider Business Mailing Address
First Line	:	2611 SENTER RD STE 212
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95111-1186
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2611 SENTER RD STE 212
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95111-1186
Country	:	US
Telephone Number	:	213-321-4125
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	TU PHUNG
Credential	:
Telephone Number	:	213-321-4125

Provider Enumeration Date	:	09/30/2020
Last Update Date	:	09/30/2020

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