Healthcare Provider Details

I. General information

NPI: 1245077742
Provider Name (Legal Business Name): MOPRIDE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2024
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 12TH ST STE 2
MODESTO CA
95354-2410
US

IV. Provider business mailing address

400 12TH ST STE 2
MODESTO CA
95354-2410
US

V. Phone/Fax

Practice location:
  • Phone: 209-567-2124
  • Fax:
Mailing address:
  • Phone: 209-567-2124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name: BRITNI LLOYD
Title or Position: CENTER MANAGER
Credential:
Phone: 209-499-0328