Healthcare Provider Details

I. General information

NPI: 1568139384
Provider Name (Legal Business Name): TRACI HAGEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2021
Last Update Date: 08/28/2021
Certification Date: 08/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 MCHENRY AVE
MODESTO CA
95350-4352
US

IV. Provider business mailing address

1707 MCHENRY AVE
MODESTO CA
95350-4352
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-4773
  • Fax:
Mailing address:
  • Phone: 209-526-4773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number1607371
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: