Provider Demographics
NPI:1154741783
Name:TO BE PRIMARY CARE
Entity type:Organization
Organization Name:TO BE PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:THAO
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-321-8542
Mailing Address - Street 1:PO BOX 2266
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95015-2266
Mailing Address - Country:US
Mailing Address - Phone:707-321-8542
Mailing Address - Fax:
Practice Address - Street 1:15215 NATIONAL AVE
Practice Address - Street 2:STE 104
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2425
Practice Address - Country:US
Practice Address - Phone:707-321-8542
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-22
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76835261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA123347Medicare PIN