Healthcare Provider Details

I. General information

NPI: 1700830296
Provider Name (Legal Business Name): EAST VALLEY COMMUNITY CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2470 ALVIN AVE SUITE 60
SAN JOSE CA
95121-1664
US

IV. Provider business mailing address

1691 THE ALAMEDA
SAN JOSE CA
95126-2203
US

V. Phone/Fax

Practice location:
  • Phone: 408-274-7100
  • Fax: 408-274-8763
Mailing address:
  • Phone: 408-795-3600
  • Fax: 408-287-0405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number070000036
License Number StateCA

VIII. Authorized Official

Name: RAYROZ DODSON-CRAWFORD
Title or Position: CFO
Credential:
Phone: 408-795-3607