Healthcare Provider Details

I. General information

NPI: 1306783147
Provider Name (Legal Business Name): ETERNITY CARE HOME 2
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 W GRANGER AVE
MODESTO CA
95350-4255
US

IV. Provider business mailing address

518 W GRANGER AVE
MODESTO CA
95350-4255
US

V. Phone/Fax

Practice location:
  • Phone: 209-450-7283
  • Fax: 209-567-2761
Mailing address:
  • Phone: 209-450-7283
  • Fax: 209-567-2761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MARIA PETALLO PAYLA
Title or Position: LICENSEE
Credential: ADMINISTRATOR
Phone: 209-450-7283