Healthcare Provider Details

I. General information

NPI: 1720315161
Provider Name (Legal Business Name): BAY AREA SPORTS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2009
Last Update Date: 11/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 S SAN MATEO DR SUITE 470
SAN MATEO CA
94401-3857
US

IV. Provider business mailing address

1800 SULLIVAN AVE SUITE 402
DALY CITY CA
94015-2228
US

V. Phone/Fax

Practice location:
  • Phone: 650-348-5400
  • Fax:
Mailing address:
  • Phone: 650-992-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberFNP 38941
License Number StateCA

VIII. Authorized Official

Name: LAURA N SCIARONI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 650-992-7700