=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356830947
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STOCKTON PACE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2018
-----------------------------------------------------
Last Update Date | 11/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 582 E. HARDING WAY
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-242-5908
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 N BARRANCA AVE # 4051
-----------------------------------------------------
City | COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91723-1722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-442-6077
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | KATHERINE THOMAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 209-697-2632
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251T00000X
-----------------------------------------------------
Taxonomy Name | PACE Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------