Healthcare Provider Details

I. General information

NPI: 1972322444
Provider Name (Legal Business Name): KO VUE PPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 10/10/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43545 BRYANT ST
FREMONT CA
94539
US

IV. Provider business mailing address

43545 BRYANT ST
FREMONT CA
94539
US

V. Phone/Fax

Practice location:
  • Phone: 510-656-1200
  • Fax:
Mailing address:
  • Phone: 510-656-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number210052740
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: