MEDICARE: O'CONNOR WOODS HOUSING CORPORATION

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	314000000X	Skilled Nursing Facility	100000631	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	100000631	OTHER	CA	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1730269184
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	O'CONNOR WOODS HOUSING CORPORATION

Provider Business Mailing Address
First Line	:	3400 WAGNER HEIGHTS RD
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95209-4843
Country	:	US
Telephone Number	:	209-956-3400
Fax Number	:

Provider Business Practice Location Address
First Line	:	3110 WAGNER HEIGHTS RD
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95209-4848
Country	:	US
Telephone Number	:	209-956-3444
Fax Number	:	209-956-3454

Authorized Official
Title or Position	:	CEO
Name	:	PENNY MALLETTE
Credential	:
Telephone Number	:	209-956-3400

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	10/30/2025

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