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General NPI Number Information
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NPI Number | 1467767541
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Entity Type | Organization
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Legal Business Name | THEODORE E. STAAHL MD INC
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Dates
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Enumeration Date | 08/12/2010
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Last Update Date | 11/09/2022
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Provider Practice Location Address
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Address Line | 1329 SPANOS CT SUITE A-1
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City | MODESTO
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State | CA
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Zip | 95355-2806
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Country | US
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Telephone | 209-577-5700
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Fax | 209-577-5968
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Provider Business Mailing Address
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Address Line | 1329 SPANOS CT SUITE A-1
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City | MODESTO
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State | CA
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Zip | 95355-2806
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Country | US
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Telephone | 209-577-5700
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Fax | 209-577-5968
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Authorized Official
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Title or Position | ADMINISTRATOR/OFFICE MANAGER
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Name | MRS. NANCY STAAHL
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Credential |
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Telephone | 209-577-5700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | G37452
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License Number State | CA
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