Healthcare Provider Details

I. General information

NPI: 1023766185
Provider Name (Legal Business Name): LUTHERAN SOCIAL SERVICES OF NORTHERN CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2022
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 N PERSHING AVE STE 120
STOCKTON CA
95207-6737
US

IV. Provider business mailing address

4390 47TH AVE
SACRAMENTO CA
95824-3700
US

V. Phone/Fax

Practice location:
  • Phone: 916-900-6140
  • Fax:
Mailing address:
  • Phone: 916-900-6140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MIXTLICOATL R GONZALEZ
Title or Position: DATA SYSTEMS MANAGER
Credential:
Phone: 916-900-0614