Provider Demographics
NPI:1518364504
Name:NORTH MODESTO FAMILY RESOURCE CENTER
Entity Type:Organization
Organization Name:NORTH MODESTO FAMILY RESOURCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QA COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRONKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-523-4610
Mailing Address - Street 1:100 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0510
Mailing Address - Country:US
Mailing Address - Phone:209-523-4573
Mailing Address - Fax:
Practice Address - Street 1:2020 STANDIFORD AVE
Practice Address - Street 2:SUITE C1
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6529
Practice Address - Country:US
Practice Address - Phone:209-338-0279
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SIERRA VISTA CHILD & FAMILY SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health