Healthcare Provider Details

I. General information

NPI: 1962039701
Provider Name (Legal Business Name): JODY BECKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 5TH ST
MODESTO CA
95351-3316
US

IV. Provider business mailing address

609 5TH ST
MODESTO CA
95351-3316
US

V. Phone/Fax

Practice location:
  • Phone: 209-341-0718
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: