MEDICARE: PUBLIC HEALTH SERVICES

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	251B00000X	Case Management Agency	377440	CA

General Provider Information

NPI Number	:	1386059541
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUBLIC HEALTH SERVICES

Provider Business Mailing Address
First Line	:	1601 E. HAZELTON AVE.
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95201
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 E. HAZELTON AVE.
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95201-2009
Country	:	US
Telephone Number	:	209-468-3892
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM MANAGER
Name	:	FLOREIDA QUIAOIT
Credential	:
Telephone Number	:	209-468-3892

Provider Enumeration Date	:	06/26/2014
Last Update Date	:	06/26/2014

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