Healthcare Provider Details

I. General information

NPI: 1144260811
Provider Name (Legal Business Name): WELLBOUND OF STOCKTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 DEER PARK DR SUITE 140
STOCKTON CA
95219-2306
US

IV. Provider business mailing address

300 SANTANA ROW SUITE 300
SAN JOSE CA
95128-2423
US

V. Phone/Fax

Practice location:
  • Phone: 209-955-5630
  • Fax: 209-955-5635
Mailing address:
  • Phone: 209-955-5630
  • Fax: 650-625-6007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BERNADETTE VINCENT
Title or Position: PRESIDENT/COO
Credential:
Phone: 650-404-3600