Healthcare Provider Details

I. General information

NPI: 1194779439
Provider Name (Legal Business Name): VERICARE OF CALIFORNIA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/11/2017
Certification Date:
Deactivation Date: 04/11/2007
Reactivation Date: 10/16/2007

III. Provider practice location address

2501 ALVIN AVE
SAN JOSE CA
95121-1660
US

IV. Provider business mailing address

55 HATCHETTS HILL RD
OLD LYME CT
06371-1534
US

V. Phone/Fax

Practice location:
  • Phone: 800-257-8715
  • Fax: 800-819-1655
Mailing address:
  • Phone: 800-370-3651
  • Fax: 877-515-7147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateCA

VIII. Authorized Official

Name: MELISSA KING
Title or Position: DIRECTOR, CREDENTIALING ENROLLMENT
Credential:
Phone: 800-370-3651