Healthcare Provider Details

I. General information

NPI: 1548697444
Provider Name (Legal Business Name): NORTH EAST MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2013
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 LUNDY AVE
SAN JOSE CA
95131-1826
US

IV. Provider business mailing address

2171 JUNIPERO SERRA BLVD STE 700
DALY CITY CA
94014-1982
US

V. Phone/Fax

Practice location:
  • Phone: 408-573-9686
  • Fax: 408-573-9685
Mailing address:
  • Phone: 415-391-9686
  • Fax: 415-433-4726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. EDDIE W CHAN
Title or Position: PRESIDENT & CEO
Credential: PHARMD
Phone: 415-391-9686