Basic Information
| Provider Information | |||||||||
| NPI: | 1407029267 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MISSION AREA HEALTH ASSOCIATES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MISSION NEIGHBORHOOD HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 240 SHOTWELL ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941101323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4155523870 | ||||||||
| FaxNumber: | 4154313178 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 SHOTWELL ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941101323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4155523870 | ||||||||
| FaxNumber: | 4154313178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2008 | ||||||||
| LastUpdateDate: | 04/11/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SIU | ||||||||
| AuthorizedOfficialFirstName: | SILVIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4155521013 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MISSION AREA HEALTH ASSOCIATES | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FHC11005F | 01 | CA | CA MEDI-CAL PROVIDER | OTHER |