Healthcare Provider Details

I. General information

NPI: 1699943654
Provider Name (Legal Business Name): MOTHER CYNTHIA'S RESIDENTIAL CARE FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 SHAFFER RD
ATWATER CA
95301-4448
US

IV. Provider business mailing address

P.O. BOX 1554
ATWATER CA
95301
US

V. Phone/Fax

Practice location:
  • Phone: 209-357-0613
  • Fax:
Mailing address:
  • Phone:
  • Fax: 209-357-8249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number247204044
License Number StateCA

VIII. Authorized Official

Name: MRS. PATRICIA ANN BUNTS
Title or Position: LISCENSEE/ADMINISTRATOR
Credential:
Phone: 209-357-0613