Healthcare Provider Details

I. General information

NPI: 1558619270
Provider Name (Legal Business Name): SAN JOAQUIN COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 N CALIFORNIA ST
STOCKTON CA
95202-1515
US

IV. Provider business mailing address

1414 N CALIFORNIA ST
STOCKTON CA
95202-1515
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-2385
  • Fax: 209-468-8024
Mailing address:
  • Phone: 209-468-2385
  • Fax: 209-468-8024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE M WARTHAN
Title or Position: MSW INTERN
Credential:
Phone: 209-406-1757