Basic Information
| Provider Information | |||||||||
| NPI: | 1043263189 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLANNED PARENTHOOD MAR MONTE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1691 THE ALAMEDA | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951262203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4087953600 | ||||||||
| FaxNumber: | 4082870405 | ||||||||
| Practice Location | |||||||||
| Address1: | 1691 THE ALAMEDA | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951262203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4087953600 | ||||||||
| FaxNumber: | 4089716963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 07/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | MOTSIFF | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4087953707 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MHA,CMA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | CLN 436 | CA | N | Suppliers | Non-Pharmacy Dispensing Site | 261QC1500X | 070000101 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | ZZR11417F | 05 | CA | MEDICAID |