Healthcare Provider Details

I. General information

NPI: 1174955587
Provider Name (Legal Business Name): CCCMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2013
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1149 FERNWOOD DR
MILLBRAE CA
94030-1011
US

IV. Provider business mailing address

27206 CALAROGA AVE
HAYWARD CA
94545-4300
US

V. Phone/Fax

Practice location:
  • Phone: 650-302-5864
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22677
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License Number22677
License Number StateCA

VIII. Authorized Official

Name: ASH JAIN
Title or Position: CEO
Credential:
Phone: 510-796-0222