Provider Demographics
NPI:1609439108
Name:GARCIA, ENEDELIA N/A
Entity Type:Individual
Prefix:
First Name:ENEDELIA
Middle Name:N/A
Last Name:GARCIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ENEDELIA
Other - Middle Name:
Other - Last Name:AGUALLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:820 SCENIC DR BLDG K
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6131
Mailing Address - Country:US
Mailing Address - Phone:209-303-0506
Mailing Address - Fax:209-558-4332
Practice Address - Street 1:820 SCENIC DR BLDG K
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6131
Practice Address - Country:US
Practice Address - Phone:209-303-0506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAA3327766374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator