Healthcare Provider Details

I. General information

NPI: 1588434849
Provider Name (Legal Business Name): POTENTIAL WAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 01/08/2024
Certification Date: 01/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12901 E HIGHWAY 20
CLEARLAKE OAKS CA
95423-9326
US

IV. Provider business mailing address

PO BOX 516
CLEARLAKE OAKS CA
95423-0516
US

V. Phone/Fax

Practice location:
  • Phone: 916-613-0098
  • Fax: 707-703-5792
Mailing address:
  • Phone: 916-613-0098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. JACQUELINE MARIE KELLY
Title or Position: CEO
Credential: RN
Phone: 916-613-0098