=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538529052
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDIAN HEALTH CENTER OF SANTA CLARA VALLEY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2016
-----------------------------------------------------
Last Update Date | 02/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 N 14TH ST STE 140
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95112-6218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-445-3400
-----------------------------------------------------
Fax | 408-448-1727
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1333 MERIDIAN AVE
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95125-5212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-445-3400
-----------------------------------------------------
Fax | 408-448-1727
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | DR. ALDON WAYNE SCOTT
-----------------------------------------------------
Credential | DOCTOR OF MANAGEMENT
-----------------------------------------------------
Telephone | 408-445-3400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 070000482
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number | 070000118
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------