Healthcare Provider Details

I. General information

NPI: 1245368653
Provider Name (Legal Business Name): A.WHITEBREAD RNFA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 SANDALWOOD DR
MODESTO CA
95350-3819
US

IV. Provider business mailing address

1702 SANDALWOOD DR
MODESTO CA
95350-3819
US

V. Phone/Fax

Practice location:
  • Phone: 209-872-6316
  • Fax:
Mailing address:
  • Phone: 209-872-6316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number411562
License Number StateCA

VIII. Authorized Official

Name: MISS ANNA MARIE WHITEBREAD
Title or Position: REGISTERED NURSE FIRST ASSIST
Credential: R.N.F.A.
Phone: 209-872-6316