=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245647908
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEMAZCAL FAMILY CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2014
-----------------------------------------------------
Last Update Date | 07/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39277 LIBERTY ST BLDG D
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94538-1519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-677-0904
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39277 LIBERTY ST BLDG D
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94538-1519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LILIANA TOMONA YAMASHIRO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 408-677-0904
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 110242
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------