Healthcare Provider Details

I. General information

NPI: 1588131395
Provider Name (Legal Business Name): BAASC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2018
Last Update Date: 02/05/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4215 HAMILTON AVE
SAN JOSE CA
95130-1462
US

IV. Provider business mailing address

4215 HAMILTON AVE
SAN JOSE CA
95130-1462
US

V. Phone/Fax

Practice location:
  • Phone: 408-761-5847
  • Fax: 408-761-5847
Mailing address:
  • Phone: 408-761-5847
  • Fax: 408-761-5847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State

VIII. Authorized Official

Name: MS. BARBARA LEE ROTH
Title or Position: PRESIDENT
Credential: RN
Phone: 408-761-5847