MEDICARE: SAN JOSE FOOTHILL FAMILY COMMUNITY CLINIC, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1104244821
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN JOSE FOOTHILL FAMILY COMMUNITY CLINIC, INC.

Provider Business Mailing Address
First Line	:	2670 SOUTH WHITE ROAD
Second Line	:	SUITE 200
City	:	SAN JOSE
State	:	CA
Zip	:	95148-2071
Country	:	US
Telephone Number	:	408-729-4290
Fax Number	:	866-931-7822

Provider Business Practice Location Address
First Line	:	3200 SENTER ROAD
Second Line	:	ROOM S-104
City	:	SAN JOSE
State	:	CA
Zip	:	95111-1332
Country	:	US
Telephone Number	:	408-347-4240
Fax Number	:	866-931-7822

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. SALVADOR CHAVARIN
Credential	:
Telephone Number	:	408-729-4290

Provider Enumeration Date	:	03/31/2014
Last Update Date	:	06/09/2015

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