Healthcare Provider Details

I. General information

NPI: 1669903852
Provider Name (Legal Business Name): MODESTO ADULT DAY PROGRAM PARTNERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3217 TULLY RD
MODESTO CA
95350-0832
US

IV. Provider business mailing address

3217 TULLY RD
MODESTO CA
95350-0832
US

V. Phone/Fax

Practice location:
  • Phone: 209-622-0963
  • Fax: 209-661-4903
Mailing address:
  • Phone: 209-622-0963
  • Fax: 209-661-4903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number502700147
License Number StateCA

VIII. Authorized Official

Name: MR. RUSSELL N MILNES
Title or Position: GENERAL PARTNER/ADMINISTRATOR
Credential:
Phone: 209-622-0963