Provider Demographics
NPI:1477026334
Name:CHILDREN'S HOME OF STOCKTON
Entity Type:Organization
Organization Name:CHILDREN'S HOME OF STOCKTON
Other - Org Name:TRIPLEX COTTAGES
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOELLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-466-0853
Mailing Address - Street 1:430 N PILGRIM ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-4428
Mailing Address - Country:US
Mailing Address - Phone:209-466-0853
Mailing Address - Fax:
Practice Address - Street 1:1227 E LINDSAY ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-4410
Practice Address - Country:US
Practice Address - Phone:209-466-0853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S HOME OF STOCKTON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-03
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA390332238Medicaid