=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194712109
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXECUTIVE ENDOSCOPY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 FOREST AVE 109
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95128-1422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-297-2314
-----------------------------------------------------
Fax | 408-297-2414
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2100 FOREST AVE 109
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95128-1422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-297-2314
-----------------------------------------------------
Fax | 408-297-2414
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. MARIBEL RIVERA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 408-297-2314
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------