Healthcare Provider Details

I. General information

NPI: 1700717741
Provider Name (Legal Business Name): KEVIN JUSCAMAYTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 N 1ST ST
SAN JOSE CA
95112-4041
US

IV. Provider business mailing address

485 N 1ST ST
SAN JOSE CA
95112-4041
US

V. Phone/Fax

Practice location:
  • Phone: 510-317-1444
  • Fax:
Mailing address:
  • Phone: 510-317-1444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberRN95435404
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95435404
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: