Healthcare Provider Details

I. General information

NPI: 1902132806
Provider Name (Legal Business Name): BAY AREA COMMUNITY DIABETES EDUCATORS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2009
Last Update Date: 05/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 S BASCOM AVE STE 26
SAN JOSE CA
95128-3509
US

IV. Provider business mailing address

1150 S BASCOM AVE STE 26
SAN JOSE CA
95128-3509
US

V. Phone/Fax

Practice location:
  • Phone: 408-998-2325
  • Fax: 408-998-2022
Mailing address:
  • Phone: 408-998-2325
  • Fax: 408-998-2022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number153880
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number2091-0313
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number931788
License Number StateCA

VIII. Authorized Official

Name: CHIANG LAM
Title or Position: PRESIDENT
Credential:
Phone: 408-998-2325