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General NPI Number Information
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NPI Number | 1720207418
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Entity Type | Organization
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Legal Business Name | MODESTO RESIDENTIAL LIVING CENTER
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Dates
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Enumeration Date | 04/24/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1932 EVERGREEN AVE
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City | MODESTO
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State | CA
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Zip | 95350-3738
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Country | US
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Telephone | 209-530-9300
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Fax | 209-530-9303
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Provider Business Mailing Address
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Address Line | 1932 EVERGREEN AVE
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City | MODESTO
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State | CA
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Zip | 95350-3738
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Country | US
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Telephone | 209-530-9300
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Fax | 209-530-9303
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Authorized Official
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Title or Position | OWNER
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Name | MR. DENNIS A MONTEROSSO
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Credential |
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Telephone | 209-530-9300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State | CA
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