MEDICARE: EXECUTIVE ENDOSCOPY, 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	261QA1903X	Ambulatory Surgical Clinic/Center		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194712109
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXECUTIVE ENDOSCOPY, INC

Provider Business Mailing Address
First Line	:	2100 FOREST AVE
Second Line	:	109
City	:	SAN JOSE
State	:	CA
Zip	:	95128-1422
Country	:	US
Telephone Number	:	408-297-2314
Fax Number	:	408-297-2414

Provider Business Practice Location Address
First Line	:	2100 FOREST AVE
Second Line	:	109
City	:	SAN JOSE
State	:	CA
Zip	:	95128-1422
Country	:	US
Telephone Number	:	408-297-2314
Fax Number	:	408-297-2414

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. MARIBEL RIVERA
Credential	:
Telephone Number	:	408-297-2314

Provider Enumeration Date	:	10/04/2005
Last Update Date	:	08/22/2020

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Directions to “EXECUTIVE ENDOSCOPY, INC ” Practice Location

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