Healthcare Provider Details

I. General information

NPI: 1366674210
Provider Name (Legal Business Name): ADVANCE KIDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2009
Last Update Date: 04/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9755 LINCOLN VILLAGE DR
SACRAMENTO CA
95827-3334
US

IV. Provider business mailing address

9755 LINCOLN VILLAGE DR
SACRAMENTO CA
95827-3334
US

V. Phone/Fax

Practice location:
  • Phone: 916-363-6103
  • Fax: 916-244-0594
Mailing address:
  • Phone: 916-363-6103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE WENELL
Title or Position: CEO PRESIDENT
Credential:
Phone: 916-363-6103