Basic Information
| Provider Information | |||||||||
| NPI: | 1093910275 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF STANISLAUS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | STANISLAUS COUNTY HEALTH SERVICES AGENCY MCHENRY MEDICAL OFFICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1209 WOODROW AVE | ||||||||
| Address2: | STE. B-10 | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953501288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095585312 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1209 WOODROW AVE | ||||||||
| Address2: | STE. B-10 | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953501288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095585312 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 03/17/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | MARY ANN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2095587163 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | CMM70751F | 01 | CA | MEDICAL | OTHER | FHC70751F | 01 | MEDICAL | OTHER | HAP70751F | 01 | CA | FAMILY PACT | OTHER |