=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508675729
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GBC MODESTO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2025
-----------------------------------------------------
Last Update Date | 01/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3600 SISK RD
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95356-0535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-828-8476
-----------------------------------------------------
Fax | 877-252-3970
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5841 N WALNUT RD
-----------------------------------------------------
City | TURLOCK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95382-9528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-604-5969
-----------------------------------------------------
Fax | 877-252-3970
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | LINDA YOUSEF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 877-828-8476
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------