Healthcare Provider Details

I. General information

NPI: 1386529238
Provider Name (Legal Business Name): JAMES DEXTER GLOVER SUDRC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2025
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 RICHLAND AVE
CERES CA
95307-4562
US

IV. Provider business mailing address

213 PHILLIP CT
MODESTO CA
95350-3524
US

V. Phone/Fax

Practice location:
  • Phone: 209-541-2121
  • Fax:
Mailing address:
  • Phone: 209-241-6250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-YKQVPF
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20800
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: