{
"Npi": {
"NPI": "1598644304",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "BOYS & GIRLS CLUBS OF STANISLAUS COUNTY",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "819 17TH ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MODESTO",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "95354-1250",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "209-222-5826",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "819 17TH ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "MODESTO",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "95354-1250",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "209-222-5826",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "08/27/2025",
"LastUpdateDate": "08/27/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MARTINEZ",
"AuthorizedOfficialFirstName": "JEREMY",
"AuthorizedOfficialMiddleName": "JAMES",
"AuthorizedOfficialTitle": "CEO",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MPA, CCMC",
"AuthorizedOfficialTelephoneNumber": "209-222-5826",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "171M00000X",
"TaxonomyName": "Case Manager/Care Coordinator",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "3747P1801X",
"TaxonomyName": "Personal Care Attendant",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "376J00000X",
"TaxonomyName": "Homemaker",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "251X00000X",
"TaxonomyName": "Supports Brokerage Agency",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
]
}
}
}