Healthcare Provider Details

I. General information

NPI: 1861972804
Provider Name (Legal Business Name): ANGEL GARCIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 RICHLAND AVE BLDG A
CERES CA
95307-4562
US

IV. Provider business mailing address

3313 SISKIYOU WAY
MODESTO CA
95350-0377
US

V. Phone/Fax

Practice location:
  • Phone: 209-300-8800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number614192
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: