Healthcare Provider Details

I. General information

NPI: 1740307719
Provider Name (Legal Business Name): CARLA JEAN SKILES B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 N CALIFORNIA ST
STOCKTON CA
95202-1552
US

IV. Provider business mailing address

1127 13TH ST
MODESTO CA
95354-0907
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-0910
  • Fax: 209-468-3516
Mailing address:
  • Phone: 209-558-7454
  • Fax: 209-558-4092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: