MEDICARE: TASSAJARA CRITICAL CARE GROUP

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1144894650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TASSAJARA CRITICAL CARE GROUP

Provider Business Mailing Address
First Line	:	5401 NORRIS CANYON RD STE 308
Second Line	:
City	:	SAN RAMON
State	:	CA
Zip	:	94583-5408
Country	:	US
Telephone Number	:	925-866-8822
Fax Number	:	925-866-8323

Provider Business Practice Location Address
First Line	:	5401 NORRIS CANYON RD STE 308
Second Line	:
City	:	SAN RAMON
State	:	CA
Zip	:	94583-5408
Country	:	US
Telephone Number	:	925-866-8822
Fax Number	:	925-866-8323

Authorized Official
Title or Position	:	OFFICE ADMINISTRATOR
Name	:	OLGA GOMEZ
Credential	:
Telephone Number	:	925-866-8822

Provider Enumeration Date	:	05/19/2021
Last Update Date	:	09/17/2021

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