Healthcare Provider Details

I. General information

NPI: 1326065160
Provider Name (Legal Business Name): DIABETES SOCIETY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 LINCOLN AVE #300
SAN JOSE CA
95125-3038
US

IV. Provider business mailing address

1165 LINCOLN AVE #300
SAN JOSE CA
95125-3038
US

V. Phone/Fax

Practice location:
  • Phone: 408-287-3785
  • Fax: 408-287-2701
Mailing address:
  • Phone: 408-287-3785
  • Fax: 408-287-2701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name: MRS. CAROL D KASSOUF
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 510-331-8620