Healthcare Provider Details

I. General information

NPI: 1700134103
Provider Name (Legal Business Name): KNEE CENTERS NOCAL MEDICAL PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 STEVENSON BLVD
FREMONT CA
94538-2317
US

IV. Provider business mailing address

585 W 500 S SUITE 120
BOUNTIFUL UT
84010-8199
US

V. Phone/Fax

Practice location:
  • Phone: 510-791-5633
  • Fax: 510-791-5634
Mailing address:
  • Phone: 801-617-2100
  • Fax: 801-208-7050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA78391
License Number StateCA

VIII. Authorized Official

Name: PAUL HUGHES
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 650-504-8151