Healthcare Provider Details

I. General information

NPI: 1831904796
Provider Name (Legal Business Name): IDA BALIGOD CLINIC NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40910 FREMONT BLVD
FREMONT CA
94538-4375
US

IV. Provider business mailing address

38043 MILLER PL
FREMONT CA
94536-3825
US

V. Phone/Fax

Practice location:
  • Phone: 510-770-8040
  • Fax:
Mailing address:
  • Phone: 408-674-8112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number345998
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: