Healthcare Provider Details

I. General information

NPI: 1316116171
Provider Name (Legal Business Name): VIDA LORRAINE BLAKELY MFTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. VIDA LORRAINE HARVEY

II. Dates (important events)

Enumeration Date: 02/26/2008
Last Update Date: 02/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 MCHENRY VILLAGE WAY SUITE11
MODESTO CA
95350-4308
US

IV. Provider business mailing address

1227 COUNTRYSIDE LN
MANTECA CA
95337-6700
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-1476
  • Fax: 209-526-0908
Mailing address:
  • Phone: 510-828-3037
  • Fax: 209-629-8790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: