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General NPI Number Information
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NPI Number | 1174955587
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Entity Type | Organization
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Legal Business Name | CCCMA
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Dates
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Enumeration Date | 08/07/2013
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Last Update Date | 08/07/2013
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Provider Practice Location Address
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Address Line | 1149 FERNWOOD DR
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City | MILLBRAE
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State | CA
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Zip | 94030-1011
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Country | US
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Telephone | 650-302-5864
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Fax |
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Provider Business Mailing Address
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Address Line | 27206 CALAROGA AVE
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City | HAYWARD
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State | CA
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Zip | 94545-4300
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | ASH JAIN
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Credential |
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Telephone | 510-796-0222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 22677
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 282E00000X
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Taxonomy Name | Long Term Care Hospital
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License Number | 22677
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License Number State | CA
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