MEDICARE: CARCIDO'S ICF 2

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	LTC60707F	CA

General Provider Information

NPI Number	:	1033326798
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARCIDO'S ICF 2

Provider Business Mailing Address
First Line	:	PO BOX 690097
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95269-0097
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1949 WAGNER HEIGHTS RD
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95209-1846
Country	:	US
Telephone Number	:	209-951-2074
Fax Number	:

Authorized Official
Title or Position	:	LICENSEE
Name	:	MRS. MEDINA CARCIDO
Credential	:
Telephone Number	:	209-471-0814

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	08/22/2020

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