Healthcare Provider Details

I. General information

NPI: 1407217425
Provider Name (Legal Business Name): CHI THAO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2016
Last Update Date: 06/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 MCHENRY AVE
MODESTO CA
95350-5370
US

IV. Provider business mailing address

1001 NEEDHAM ST.
MODESTO CA
95354-5370
US

V. Phone/Fax

Practice location:
  • Phone: 209-527-4597
  • Fax:
Mailing address:
  • Phone: 209-569-0373
  • Fax: 209-529-8519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: