Healthcare Provider Details

I. General information

NPI: 1457485617
Provider Name (Legal Business Name): TUOLUMNE COUNTY CCS - SOULSBYVILLE MTU
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20300 SOULSBYVILLE RD
SOULSBYVILLE CA
95372-9738
US

IV. Provider business mailing address

2 S GREEN ST
SONORA CA
95370-4618
US

V. Phone/Fax

Practice location:
  • Phone: 209-532-5198
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATHY AMOS
Title or Position: DIRECTOR OF PUBLIC HEALTH NURSING
Credential:
Phone: 209-533-7403