Healthcare Provider Details

I. General information

NPI: 1194048884
Provider Name (Legal Business Name): GENESIS CLINICA DE LA MUJER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2010
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 N JACKSON AVE SUITE 209
SAN JOSE CA
95116-1604
US

IV. Provider business mailing address

244 N JACKSON AVE SUITE 209
SAN JOSE CA
95116-1604
US

V. Phone/Fax

Practice location:
  • Phone: 408-258-3724
  • Fax: 408-258-3736
Mailing address:
  • Phone: 408-258-3724
  • Fax: 408-258-3736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG75190
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberNP9507
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberG81814
License Number StateCA

VIII. Authorized Official

Name: MRS. ROSA ELENA HEREDIA
Title or Position: PRESIDENT
Credential: MSN
Phone: 408-258-3724