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NPI Code Detail

MEDICARE: ADVANCE KIDS

MEDICARE: ADVANCE KIDS
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
1252Y00000XEarly Intervention Provider Agency
2103K00000XBehavior Analyst

General Provider Information

NPI Number : 1366674210
Entity Type Code : Organization
Provider Name (Legal Business Name) : ADVANCE KIDS
Provider Business Mailing Address
First Line : 9755 LINCOLN VILLAGE DR
Second Line :
City : SACRAMENTO
State : CA
Zip : 95827-3334
Country : US
Telephone Number : 916-363-6103
Fax Number :
Provider Business Practice Location Address
First Line : 9755 LINCOLN VILLAGE DR
Second Line :
City : SACRAMENTO
State : CA
Zip : 95827-3334
Country : US
Telephone Number : 916-363-6103
Fax Number : 916-244-0594
Authorized Official
Title or Position : CEO PRESIDENT
Name : MICHELLE WENELL
Credential :
Telephone Number : 916-363-6103
Provider Enumeration Date : 08/11/2009
Last Update Date : 04/26/2018

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95827-3334
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SACRAMENTO, CA
95827-3334
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1407101843 — MICHELLE WAGNER B.C.B.A
Practice Location Address:
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95827-3334
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Directions to “ADVANCE KIDS ” Practice Location

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