Healthcare Provider Details

I. General information

NPI: 1912537770
Provider Name (Legal Business Name): ECMO PRN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2020
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1246 MISSION RD
SOUTH SAN FRANCISCO CA
94080-1212
US

IV. Provider business mailing address

1246 MISSION RD
SOUTH SAN FRANCISCO CA
94080-1212
US

V. Phone/Fax

Practice location:
  • Phone: 510-274-0789
  • Fax:
Mailing address:
  • Phone: 510-274-0789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. JASON CHAN
Title or Position: CEO
Credential: RN, MSN, CCRN-K
Phone: 510-274-0789