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General NPI Number Information
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NPI Number | 1346667367
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Entity Type | Organization
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Legal Business Name | NORTHERN CALIFORNIA YOUTH CENTER
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Dates
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Enumeration Date | 03/27/2014
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Last Update Date | 03/27/2014
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Provider Practice Location Address
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Address Line | 7650 NEWCASTLE RD
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City | STOCKTON
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State | CA
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Zip | 95215-9663
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Country | US
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Telephone | 209-463-9085
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Fax | 209-465-8627
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Provider Business Mailing Address
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Address Line | PO BOX 213004
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City | STOCKTON
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State | CA
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Zip | 95213-9004
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Country | US
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Telephone | 209-463-9085
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Fax | 209-465-8627
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Authorized Official
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Title or Position | CHIEF OF PHYSICIANS AND SURGEONS
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Name | DR. ROBIN WONG
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Credential | D.O
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Telephone | 209-944-6365
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | LCF 35788
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License Number State | CA
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