=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376575860
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH BAY ENDOSCOPY CENTER A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2006
-----------------------------------------------------
Last Update Date | 01/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 455 OCONNOR DR SUITE 340
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95128-1633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-283-3715
-----------------------------------------------------
Fax | 408-283-3718
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 455 OCONNOR DR SUITE 340
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95128-1633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-283-3715
-----------------------------------------------------
Fax | 408-283-3718
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE/TECHNICAL COORDINATO
-----------------------------------------------------
Name | MS. LINDA M VIEIRA
-----------------------------------------------------
Credential | R.N.
-----------------------------------------------------
Telephone | 408-595-7302
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0800X
-----------------------------------------------------
Taxonomy Name | Endoscopy Clinic/Center
-----------------------------------------------------
License Number | 070000447
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------