Healthcare Provider Details

I. General information

NPI: 1790422392
Provider Name (Legal Business Name): 21ST CENTURY HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 09/02/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1743 GRAND CANAL BLVD STE 11
STOCKTON CA
95207-8108
US

IV. Provider business mailing address

1743 GRAND CANAL BLVD STE 11
STOCKTON CA
95207-8108
US

V. Phone/Fax

Practice location:
  • Phone: 209-482-3492
  • Fax: 209-451-1419
Mailing address:
  • Phone: 209-482-3492
  • Fax: 209-451-1419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: ELMAR MONTERO SIBAYAN
Title or Position: ADMINISTRATOR
Credential: DOCTOR OF PHYSICAL T
Phone: 559-802-0518