=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639264005
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN JOAQUIN COUNTY CCS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1810 HOYT LN
-----------------------------------------------------
City | MANTECA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95336-6354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-982-5159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2009
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95201-2009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-953-3617
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MTP MANAGER
-----------------------------------------------------
Name | DR. ARMANDO VALERIO
-----------------------------------------------------
Credential | PT,DPT
-----------------------------------------------------
Telephone | 209-953-3617
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number | PT23512
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------