Healthcare Provider Details

I. General information

NPI: 1588387526
Provider Name (Legal Business Name): MYLESTONES EARLY INTERVENTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 13TH ST # 108
MODESTO CA
95354-2437
US

IV. Provider business mailing address

1457 SERENO DR
MANTECA CA
95337-7000
US

V. Phone/Fax

Practice location:
  • Phone: 209-884-2424
  • Fax:
Mailing address:
  • Phone: 209-884-2424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NINA BOLING
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: ED.D., BCBA
Phone: 209-884-2424