Provider Demographics
NPI:1598644304
Name:BOYS & GIRLS CLUBS OF STANISLAUS COUNTY
Entity type:Organization
Organization Name:BOYS & GIRLS CLUBS OF STANISLAUS COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MPA, CCMC
Authorized Official - Phone:209-222-5826
Mailing Address - Street 1:819 17TH ST
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-1250
Mailing Address - Country:US
Mailing Address - Phone:209-222-5826
Mailing Address - Fax:
Practice Address - Street 1:819 17TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-1250
Practice Address - Country:US
Practice Address - Phone:209-222-5826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251X00000XAgenciesSupports Brokerage
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty