Healthcare Provider Details

I. General information

NPI: 1649673831
Provider Name (Legal Business Name): MEKONG COMMUNITY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 10/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2203 TULLY RD
SAN JOSE CA
95122-1348
US

IV. Provider business mailing address

2203 TULLY RD
SAN JOSE CA
95122-1348
US

V. Phone/Fax

Practice location:
  • Phone: 408-937-1553
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateCA

VIII. Authorized Official

Name: MINH TA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 408-937-1553