Basic Information
Provider Information | |||||||||
NPI: | 1376815282 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEALTHY CONNECTIONS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1947 N CALIFORNIA ST STE C | ||||||||
Address2: |   | ||||||||
City: | STOCKTON | ||||||||
State: | CA | ||||||||
PostalCode: | 952046029 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2094630870 | ||||||||
FaxNumber: | 2094631803 | ||||||||
Practice Location | |||||||||
Address1: | 1235 W VINE ST | ||||||||
Address2: | SUITE 20 | ||||||||
City: | LODI | ||||||||
State: | CA | ||||||||
PostalCode: | 952405144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2093397410 | ||||||||
FaxNumber: | 2093398778 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/08/2012 | ||||||||
LastUpdateDate: | 11/06/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VASTI | ||||||||
AuthorizedOfficialFirstName: | ERNEST | ||||||||
AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2094630870 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.