Healthcare Provider Details

I. General information

NPI: 1720796907
Provider Name (Legal Business Name): MODESTO GOSPEL MISSION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2022
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 YOSEMITE BLVD
MODESTO CA
95354-2840
US

IV. Provider business mailing address

PO BOX 1203
MODESTO CA
95353-1203
US

V. Phone/Fax

Practice location:
  • Phone: 209-529-8259
  • Fax:
Mailing address:
  • Phone: 529-225-2905
  • Fax: 209-529-3450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code282J00000X
TaxonomyReligious Nonmedical Health Care Institution
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: JASON ALLEN CONWAY
Title or Position: CEO
Credential:
Phone: 209-225-2905