=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932247541
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARCIES MANOR III ICF
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2007
-----------------------------------------------------
Last Update Date | 04/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1528 VENETIAN DR
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95207-5422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-952-6122
-----------------------------------------------------
Fax | 209-478-3391
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5450 SAINT ANDREWS DR
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95219-1918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-478-3391
-----------------------------------------------------
Fax | 209-478-3391
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARCIE H. PATUBO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 209-478-3391
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 100000773
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------