Healthcare Provider Details

I. General information

NPI: 1780195628
Provider Name (Legal Business Name): MA RHEA REVELINA PERSIC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 CUMMINS DR
MODESTO CA
95358-6400
US

IV. Provider business mailing address

5507 SAVAGE AVE
RIVERBANK CA
95367
US

V. Phone/Fax

Practice location:
  • Phone: 209-622-1420
  • Fax: 209-491-0627
Mailing address:
  • Phone: 209-300-1933
  • Fax: 209-491-0627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: