Healthcare Provider Details

I. General information

NPI: 1720359490
Provider Name (Legal Business Name): EASTER SEAL SOCIETY OF SUPERIOR CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2012
Last Update Date: 12/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7273 MURRAY DR STE 1
STOCKTON CA
95210-3385
US

IV. Provider business mailing address

3205 HURLEY WAY
SACRAMENTO CA
95864-3853
US

V. Phone/Fax

Practice location:
  • Phone: 209-957-3625
  • Fax: 209-957-6031
Mailing address:
  • Phone: 916-485-6711
  • Fax: 916-485-2653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: HOAN NGUYEN
Title or Position: CFO
Credential:
Phone: 916-485-6711