Healthcare Provider Details

I. General information

NPI: 1164567681
Provider Name (Legal Business Name): MR. VISARA HEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

438 N WHITE RD ALLIANCE FOR COMMUNITY CARE SERVICE TEAM OUTPATIENT
SAN JOSE CA
95127-1439
US

IV. Provider business mailing address

540 N 1ST ST
SAN JOSE CA
95112-5319
US

V. Phone/Fax

Practice location:
  • Phone: 408-254-6828
  • Fax: 408-254-6838
Mailing address:
  • Phone: 408-510-3420
  • Fax: 408-510-3427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: