Healthcare Provider Details

I. General information

NPI: 1841634144
Provider Name (Legal Business Name): WELLBOUND OF MODESTO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 12/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4207 BANGS AVE STE 200
MODESTO CA
95356-8714
US

IV. Provider business mailing address

300 SANTANA ROW STE 300
SAN JOSE CA
95128-2423
US

V. Phone/Fax

Practice location:
  • Phone: 209-338-2540
  • Fax: 209-543-3897
Mailing address:
  • Phone: 209-338-2540
  • Fax: 650-625-6007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SUSAN L DEL BENE
Title or Position: SECRETARY/CFO
Credential:
Phone: 650-404-3618