Healthcare Provider Details

I. General information

NPI: 1104663137
Provider Name (Legal Business Name): STEPHANIE RAQUEL TUNCHEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2024
Last Update Date: 07/09/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3585 HAWVER ROAD
SAN ANDREAS CA
95249
US

IV. Provider business mailing address

PO BOX 1144
SAN ANDREAS CA
95249-1144
US

V. Phone/Fax

Practice location:
  • Phone: 209-754-1249
  • Fax: 209-754-1087
Mailing address:
  • Phone: 209-754-1249
  • Fax: 209-754-1087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: