Provider Demographics
NPI:1932247541
Name:MARCIES MANOR III ICF
Entity Type:Organization
Organization Name:MARCIES MANOR III ICF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARCIE
Authorized Official - Middle Name:H
Authorized Official - Last Name:PATUBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-478-3391
Mailing Address - Street 1:5450 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-1918
Mailing Address - Country:US
Mailing Address - Phone:209-478-3391
Mailing Address - Fax:209-478-3391
Practice Address - Street 1:1528 VENETIAN DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5422
Practice Address - Country:US
Practice Address - Phone:209-952-6122
Practice Address - Fax:209-478-3391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-03
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100000773320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC61051FMedicaid