Healthcare Provider Details

I. General information

NPI: 1356685101
Provider Name (Legal Business Name): JUVENTAS WEST A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2012
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 N WINCHESTER BLVD
SANTA CLARA CA
95050-6325
US

IV. Provider business mailing address

728 COLLEEN DR
SAN JOSE CA
95123-4605
US

V. Phone/Fax

Practice location:
  • Phone: 650-888-5728
  • Fax:
Mailing address:
  • Phone: 650-888-5728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number193400000X
License Number StateCA

VIII. Authorized Official

Name: DR. TIEN TRINH
Title or Position: OWNER
Credential: MD
Phone: 408-646-5390