Healthcare Provider Details

I. General information

NPI: 1679395990
Provider Name (Legal Business Name): PORT CITY OPERATING COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E MAGNOLIA ST STE 100
STOCKTON CA
95202-1850
US

IV. Provider business mailing address

510 E MAGNOLIA ST STE 100
STOCKTON CA
95202-1850
US

V. Phone/Fax

Practice location:
  • Phone: 209-461-2054
  • Fax:
Mailing address:
  • Phone: 209-461-2054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ANDREA NICOLE OCHOA
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 209-467-6442