Healthcare Provider Details

I. General information

NPI: 1942340625
Provider Name (Legal Business Name): KELLEY PARK MEDICAL CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 08/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

749 STORY RD SUITE 20
SAN JOSE CA
95122-2600
US

IV. Provider business mailing address

749 STORY RD SUITE 20
SAN JOSE CA
95122-2600
US

V. Phone/Fax

Practice location:
  • Phone: 408-794-2088
  • Fax: 408-292-2179
Mailing address:
  • Phone: 408-794-2088
  • Fax: 408-292-2179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number20A7360
License Number StateCA

VIII. Authorized Official

Name: DR. PETER LINH NGUYEN
Title or Position: DR
Credential: D.O.
Phone: 408-794-2088