MEDICARE: CANADA COLLEGE HEALTH CENTER

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	261QS1000X	Student Health Clinic/Center

General Provider Information

NPI Number	:	1588263578
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANADA COLLEGE HEALTH CENTER

Provider Business Mailing Address
First Line	:	4200 FARM HILL BLVD
Second Line	:
City	:	REDWOOD CITY
State	:	CA
Zip	:	94061-1099
Country	:	US
Telephone Number	:	650-306-3309
Fax Number	:

Provider Business Practice Location Address
First Line	:	4200 FARM HILL BLVD
Second Line	:
City	:	REDWOOD CITY
State	:	CA
Zip	:	94061-1099
Country	:	US
Telephone Number	:	650-306-3309
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. SPENCER B WONG
Credential	:	MD
Telephone Number	:	650-306-3309

Provider Enumeration Date	:	10/21/2020
Last Update Date	:	11/04/2020

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