Provider Demographics
NPI:1720796907
Name:MODESTO GOSPEL MISSION
Entity Type:Organization
Organization Name:MODESTO GOSPEL MISSION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:CONWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-225-2905
Mailing Address - Street 1:PO BOX 1203
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95353-1203
Mailing Address - Country:US
Mailing Address - Phone:529-225-2905
Mailing Address - Fax:209-529-3450
Practice Address - Street 1:1400 YOSEMITE BLVD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-2840
Practice Address - Country:US
Practice Address - Phone:209-529-8259
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging
No251B00000XAgenciesCase Management
No282J00000XHospitalsReligious Nonmedical Health Care Institution