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General NPI Number Information
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NPI Number | 1598644304
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Entity Type | Organization
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Legal Business Name | BOYS & GIRLS CLUBS OF STANISLAUS COUNTY
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Dates
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Enumeration Date | 08/27/2025
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Last Update Date | 08/27/2025
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Provider Practice Location Address
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Address Line | 819 17TH ST
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City | MODESTO
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State | CA
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Zip | 95354-1250
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Country | US
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Telephone | 209-222-5826
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Fax |
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Provider Business Mailing Address
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Address Line | 819 17TH ST
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City | MODESTO
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State | CA
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Zip | 95354-1250
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Country | US
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Telephone | 209-222-5826
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. JEREMY JAMES MARTINEZ
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Credential | MPA, CCMC
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Telephone | 209-222-5826
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3747P1801X
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Taxonomy Name | Personal Care Attendant
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 376J00000X
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Taxonomy Name | Homemaker
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 251X00000X
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Taxonomy Name | Supports Brokerage Agency
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License Number |
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License Number State |
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