Provider Demographics
NPI:1336433283
Name:SUPPLMENTAL HEALTH CARE
Entity Type:Organization
Organization Name:SUPPLMENTAL HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:2095-234-8745
Mailing Address - Street 1:1717 MARSTON WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-1940
Mailing Address - Country:US
Mailing Address - Phone:209-523-8745
Mailing Address - Fax:
Practice Address - Street 1:1717 MARSTON WAY
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1940
Practice Address - Country:US
Practice Address - Phone:209-523-8745
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT534302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization