Healthcare Provider Details

I. General information

NPI: 1609950997
Provider Name (Legal Business Name): CHOICE MEDICAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2365 MONTPELIER DR
SAN JOSE CA
95116-1614
US

IV. Provider business mailing address

1834 STONE AVE SUITE 2B
SAN JOSE CA
95125-1306
US

V. Phone/Fax

Practice location:
  • Phone: 408-272-9244
  • Fax: 408-254-4596
Mailing address:
  • Phone: 408-995-0102
  • Fax: 408-995-0190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateCA

VIII. Authorized Official

Name: LIZA TAPIA VAUGHAN
Title or Position: GENERAL MANAGER
Credential:
Phone: 408-995-0102