Healthcare Provider Details

I. General information

NPI: 1316164379
Provider Name (Legal Business Name): CARPENTER GUEST HOMES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3446 POCK LN
STOCKTON CA
95205-8022
US

IV. Provider business mailing address

2482 CARPENTER RD
STOCKTON CA
95205
US

V. Phone/Fax

Practice location:
  • Phone: 209-932-0368
  • Fax: 209-932-0668
Mailing address:
  • Phone: 209-932-0368
  • Fax: 209-932-0668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number100000685
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number100000685
License Number StateCA

VIII. Authorized Official

Name: MRS. ESTRELLA L. JOSE
Title or Position: LICENSEE/ADMIN
Credential:
Phone: 209-462-4239