Healthcare Provider Details

I. General information

NPI: 1376788166
Provider Name (Legal Business Name): SUPPLEMENTAL HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2008
Last Update Date: 12/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 GELLERT BLVD STE 150
DALY CITY CA
94015-2690
US

IV. Provider business mailing address

333 GELLERT BLVD SUITE 150
DALY CITY CA
94015-3003
US

V. Phone/Fax

Practice location:
  • Phone: 866-758-4700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License NumberAT 8865
License Number StateCA

VIII. Authorized Official

Name: SAMMY LAGMAN
Title or Position: PTA
Credential:
Phone: 650-452-2477