Healthcare Provider Details

I. General information

NPI: 1396479606
Provider Name (Legal Business Name): JUSTIN CHAVEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 N CALIFORNIA ST # 2
STOCKTON CA
95202-1515
US

IV. Provider business mailing address

248 E DOWNS ST
STOCKTON CA
95204-2006
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-8700
  • Fax:
Mailing address:
  • Phone: 209-373-8805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number42379
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: