Provider Demographics
NPI:1831309848
Name:WILLIE DEAN
Entity Type:Organization
Organization Name:WILLIE DEAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LVN
Authorized Official - Prefix:
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-688-7720
Mailing Address - Street 1:5288 BARBADOS CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-6605
Mailing Address - Country:US
Mailing Address - Phone:209-688-7720
Mailing Address - Fax:
Practice Address - Street 1:1012 RAUBE CT
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-2417
Practice Address - Country:US
Practice Address - Phone:209-544-9377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN128313302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization