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General NPI Number Information
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NPI Number | 1568679223
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Entity Type | Organization
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Legal Business Name | CARCIDO'S ICF 3
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Dates
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Enumeration Date | 05/16/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2721 JIMENEZ WAY
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City | STOCKTON
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State | CA
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Zip | 95209-1774
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Country | US
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Telephone | 209-951-4411
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 690097
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City | STOCKTON
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State | CA
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Zip | 95269-0097
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | LICENSEE
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Name | MRS. MEDINA CARCIDO
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Credential |
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Telephone | 209-471-0814
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | LTC60768F
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License Number State | CA
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