Provider Demographics
NPI:1609264878
Name:EL CONCILIO
Entity Type:Organization
Organization Name:EL CONCILIO
Other - Org Name:EL CONCILIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILTON
Authorized Official - Middle Name:
Authorized Official - Last Name:WIELNEGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-888-8334
Mailing Address - Street 1:445 N SAN JOAQUIN ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-2026
Mailing Address - Country:US
Mailing Address - Phone:209-888-8334
Mailing Address - Fax:
Practice Address - Street 1:445 N SAN JOAQUIN ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2026
Practice Address - Country:US
Practice Address - Phone:209-888-8334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health