Healthcare Provider Details

I. General information

NPI: 1629436134
Provider Name (Legal Business Name): DMAT CA-6
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2016
Last Update Date: 08/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 LOOP RD BLDG 4, A-137
PALO ALTO CA
94304-1207
US

IV. Provider business mailing address

101 DALE AVE
SAN CARLOS CA
94070-2940
US

V. Phone/Fax

Practice location:
  • Phone: 202-731-3755
  • Fax: 650-412-1815
Mailing address:
  • Phone: 202-731-3755
  • Fax: 650-412-1815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License NumberG64161
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License NumberG64161
License Number StateCA

VIII. Authorized Official

Name: DAVID LIPIN
Title or Position: UNIT COMMANDER
Credential:
Phone: 292-731-3755