Basic Information
| Provider Information | |||||||||
| NPI: | 1629094891 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF STANISLAUS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | STANISLAUS COUNTY HEALTH SERVICES AGENCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 830 SCENIC DR | ||||||||
| Address2: | MODESTO, CA SUITE B | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953506131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095587000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 830 SCENIC DR | ||||||||
| Address2: | MODESTO, CA SUITE B | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953506131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095587000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 12/21/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | MARY ANN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2095587163 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | CMM70758F | 01 | CA | MEDICAL PROVIDER NUMBER | OTHER | ZZR11501F | 01 | CA | MEDICAL PROVIDER NUMBER | OTHER | CE0652 | 01 | MEDICARE RAILROAD | OTHER | LAB10463F | 01 | CA | MEDICAL | OTHER | BCP18531F | 01 | CA | BCEDP | OTHER | EXE70074F | 01 | CA | MEDICAL PROVIDER NUMBER | OTHER | GR0081280 | 01 | CA | MEDICAL GROUP PROVIDER N. | OTHER | HAP18531F | 01 | CA | MEDICAL | OTHER | CMM70751F | 01 | CA | MEDICAL PROVIDER NUMBER | OTHER | CMM70753F | 01 | CA | MEDICAL PROVIDER NUMBER | OTHER | CMM70759F | 01 | CA | MEDICAL PROVIDER NUMBER | OTHER | CMM70762F | 01 | CA | MEDICAL PROVIDER NUMBER | OTHER | RHM18531F | 01 | CA | MEDICAL PROVIDER NUMBER | OTHER | CMM70757F | 01 | CA | MEDICAL PROVIDER NUMBER | OTHER | CMM70760F | 01 | CA | MEDICAL PROVIDER NUMBER | OTHER |