=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114362167
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUAN HERNANDEZ RRW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2013
-----------------------------------------------------
Last Update Date | 12/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 976 LENZEN AVE SAN JOSE, ROOM 12
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95126-2737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-792-5257
-----------------------------------------------------
Fax | 408-947-8719
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 151 W MISSION ST SUITE, 100
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95110-1713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-535-4004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | R2571014
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------