Provider Demographics
NPI:1760658553
Name:MID VALLEY HEALTH SERVICES LONG TERM CARE INC
Entity Type:Organization
Organization Name:MID VALLEY HEALTH SERVICES LONG TERM CARE INC
Other - Org Name:MID VALLEY HEALTH SERVICES LONG TERM CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:STOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-552-7600
Mailing Address - Street 1:602 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6128
Mailing Address - Country:US
Mailing Address - Phone:209-552-7600
Mailing Address - Fax:209-552-7638
Practice Address - Street 1:602 SCENIC DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6128
Practice Address - Country:US
Practice Address - Phone:209-552-7600
Practice Address - Fax:209-552-7638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY498803336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2113493OtherPK