Healthcare Provider Details

I. General information

NPI: 1831309848
Provider Name (Legal Business Name): WILLIE DEAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 RAUBE CT
MODESTO CA
95351-2417
US

IV. Provider business mailing address

5288 BARBADOS CIR
STOCKTON CA
95210-6605
US

V. Phone/Fax

Practice location:
  • Phone: 209-544-9377
  • Fax:
Mailing address:
  • Phone: 209-688-7720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberVN128313
License Number StateCA

VIII. Authorized Official

Name: WILLIE RUTH DEAN
Title or Position: LVN
Credential:
Phone: 209-688-7720