Healthcare Provider Details

I. General information

NPI: 1982766549
Provider Name (Legal Business Name): KAISER PERMANENTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 EL CAMINO REAL
SOUTH SAN FRANCISCO CA
94080-3208
US

IV. Provider business mailing address

1019 MONTEREY AVE
FOSTER CITY CA
94404-3717
US

V. Phone/Fax

Practice location:
  • Phone: 650-742-1350
  • Fax: 650-742-1311
Mailing address:
  • Phone: 650-349-5676
  • Fax: 650-349-0382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number193145
License Number StateCA

VIII. Authorized Official

Name: PHYLLIS JANE MOORE
Title or Position: NP
Credential: RN
Phone: 650-742-1350