Provider Demographics
NPI:1609206846
Name:AREA 12 AGENCY ON AGING
Entity Type:Organization
Organization Name:AREA 12 AGENCY ON AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAULINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-532-6272
Mailing Address - Street 1:19074 STANDARD RD., SUITE A
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370
Mailing Address - Country:US
Mailing Address - Phone:209-532-6272
Mailing Address - Fax:209-532-6501
Practice Address - Street 1:19074 STANDARD RD STE A
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-7542
Practice Address - Country:US
Practice Address - Phone:209-532-6272
Practice Address - Fax:209-532-6501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-26
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMSS00032FMedicaid