Healthcare Provider Details

I. General information

NPI: 1396022000
Provider Name (Legal Business Name): PACE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2011
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MOORPARK AVE STE 216B
SAN JOSE CA
95128-2631
US

IV. Provider business mailing address

2400 MOORPARK AVE STE 216B
SAN JOSE CA
95128-2631
US

V. Phone/Fax

Practice location:
  • Phone: 408-885-5935
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MRS. DONNA COHEN CRETCHER
Title or Position: INTERN & TRAINEE PROGRAM COORDINATO
Credential:
Phone: 408-792-3910