Provider Demographics
NPI:1841215530
Name:MODESTO PRIMARY CARE
Entity type:Organization
Organization Name:MODESTO PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WATTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-575-4575
Mailing Address - Street 1:PO BOX 4398
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95352-4398
Mailing Address - Country:US
Mailing Address - Phone:209-575-4575
Mailing Address - Fax:
Practice Address - Street 1:2020 COFFEE RD STE J2
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2416
Practice Address - Country:US
Practice Address - Phone:209-572-0191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA17110261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0086820Medicaid
CAGR0086820Medicaid