Healthcare Provider Details

I. General information

NPI: 1962276568
Provider Name (Legal Business Name): KY VY NGO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2023
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 GATEWAY BLVD FL 2
SOUTH SAN FRANCISCO CA
94080-7401
US

IV. Provider business mailing address

801 GATEWAY BLVD FL 2
SOUTH SAN FRANCISCO CA
94080-7401
US

V. Phone/Fax

Practice location:
  • Phone: 650-573-4799
  • Fax: 650-573-1023
Mailing address:
  • Phone: 650-573-4799
  • Fax: 650-573-1023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: