MEDICARE: O'CONNOR WOODS HOUSING CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency		CA

General Provider Information

NPI Number	:	1033648084
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	O'CONNOR WOODS HOUSING CORP

Provider Business Mailing Address
First Line	:	3400 WAGNER HEIGHTS RD
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95209
Country	:	US
Telephone Number	:	209-476-4036
Fax Number	:	209-476-4042

Provider Business Practice Location Address
First Line	:	3400 WAGNER HEIGHTS RD
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95209-4843
Country	:	US
Telephone Number	:	209-476-4036
Fax Number	:	209-476-4042

Authorized Official
Title or Position	:	CONTROLLER
Name	:	ADMIRA MASIC
Credential	:	CPA
Telephone Number	:	209-956-3484

Provider Enumeration Date	:	06/05/2017
Last Update Date	:	07/21/2022

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