MEDICARE: WELLBOUND OF MODESTO LLC

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	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

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

General Provider Information

NPI Number	:	1932171972
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLBOUND OF MODESTO LLC

Provider Business Mailing Address
First Line	:	300 SANTANA ROW
Second Line	:	300
City	:	SAN JOSE
State	:	CA
Zip	:	95128-2423
Country	:	US
Telephone Number	:	209-238-4080
Fax Number	:	650-625-6007

Provider Business Practice Location Address
First Line	:	1315 10TH ST
Second Line	:	SUITE 100
City	:	MODESTO
State	:	CA
Zip	:	95354-0714
Country	:	US
Telephone Number	:	209-238-4080
Fax Number	:	209-238-4084

Authorized Official
Title or Position	:	CHAIRMAN
Name	:	THOMAS L WEINBERG
Credential	:
Telephone Number	:	214-736-2700

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	05/15/2024

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