Healthcare Provider Details

I. General information

NPI: 1164643862
Provider Name (Legal Business Name): INDIAN HEALTH CENTER OF SANTA CLARA VALLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 06/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 MERIDIAN AVE
SAN JOSE CA
95125-5212
US

IV. Provider business mailing address

1333 MERIDIAN AVE
SAN JOSE CA
95125-5212
US

V. Phone/Fax

Practice location:
  • Phone: 408-445-3400
  • Fax: 408-448-1727
Mailing address:
  • Phone: 408-445-3400
  • Fax: 408-448-1727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number070000118
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number070000118
License Number StateCA

VIII. Authorized Official

Name: DR. ALDON WAYNE SCOTT
Title or Position: DIRECTOR OF OPERATIONS
Credential: D.M.
Phone: 408-445-3400