1841634144 NPI number — WELLBOUND OF MODESTO LLC

Table of content: (NPI 1841634144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841634144 NPI number — WELLBOUND OF MODESTO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLBOUND OF MODESTO LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841634144
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 SANTANA ROW
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95128-2423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-338-2540
Provider Business Mailing Address Fax Number:
650-625-6007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4207 BANGS AVE
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
MODESTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95356-8714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-338-2540
Provider Business Practice Location Address Fax Number:
209-543-3897
Provider Enumeration Date:
04/18/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DEL BENE
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
SECRETARY/CFO
Authorized Official Telephone Number:
650-404-3618

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1841634144 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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