Healthcare Provider Details

I. General information

NPI: 1619708229
Provider Name (Legal Business Name): LEGACY ALLIANCE OUTREACH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2024
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 H ST
MODESTO CA
95354-3419
US

IV. Provider business mailing address

2601 OAKDALE RD STE 154
MODESTO CA
95355-2256
US

V. Phone/Fax

Practice location:
  • Phone: 209-480-6199
  • Fax:
Mailing address:
  • Phone: 209-480-6199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDER BEQUETTE
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 925-784-0386