Healthcare Provider Details

I. General information

NPI: 1588211825
Provider Name (Legal Business Name): LUIS MANUEL MERLOS III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 W MATHEWS RD
FRENCH CAMP CA
95231-9757
US

IV. Provider business mailing address

1414 N CALIFORNIA ST
STOCKTON CA
95202-1515
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-4240
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number125801
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: