Provider Demographics
NPI:1093910275
Name:COUNTY OF STANISLAUS
Entity Type:Organization
Organization Name:COUNTY OF STANISLAUS
Other - Org Name:STANISLAUS COUNTY HEALTH SERVICES AGENCY MCHENRY MEDICAL OFFICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-558-7163
Mailing Address - Street 1:1209 WOODROW AVE
Mailing Address - Street 2:STE. B-10
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1288
Mailing Address - Country:US
Mailing Address - Phone:209-558-5312
Mailing Address - Fax:
Practice Address - Street 1:1209 WOODROW AVE
Practice Address - Street 2:STE. B-10
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-1288
Practice Address - Country:US
Practice Address - Phone:209-558-5312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM70751FOtherMEDICAL
FHC70751FOtherMEDICAL
CAHAP70751FOtherFAMILY PACT
CAHAP70751FOtherFAMILY PACT