Provider Demographics
NPI:1952506123
Name:COUNTY OF STANISLAUS
Entity Type:Organization
Organization Name:COUNTY OF STANISLAUS
Other - Org Name:STANISLAUS COUNTY HEALTH SERVICES AGENCY CERES MEDICAL OFFICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-558-7163
Mailing Address - Street 1:3109 E WHITMORE AVE
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-2906
Mailing Address - Country:US
Mailing Address - Phone:209-541-2929
Mailing Address - Fax:
Practice Address - Street 1:3109 E WHITMORE AVE
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-2906
Practice Address - Country:US
Practice Address - Phone:209-541-2929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM70758FOtherMEDICAL
CAHAP70758FOtherFAMILY PACT
FHC70758FOtherMEDICAL
FHC70758FOtherMEDICAL