Provider Demographics
NPI:1689769986
Name:SAN JOAQUIN COUNTY CCS
Entity Type:Organization
Organization Name:SAN JOAQUIN COUNTY CCS
Other - Org Name:TRACY MTU
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MTP MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARMANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:VALERIO
Authorized Official - Suffix:
Authorized Official - Credentials:PT,DPT
Authorized Official - Phone:209-953-3617
Mailing Address - Street 1:PO BOX 2009
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-2009
Mailing Address - Country:US
Mailing Address - Phone:209-831-5952
Mailing Address - Fax:
Practice Address - Street 1:1616 CHESTER DR
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-2928
Practice Address - Country:US
Practice Address - Phone:209-831-5952
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACCS00123FMedicaid