Provider Demographics
NPI:1215440631
Name:STANISLAUS HEALTH AND WELLNESS INC
Entity type:Organization
Organization Name:STANISLAUS HEALTH AND WELLNESS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:I
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-846-9429
Mailing Address - Street 1:PO BOX 578700
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-8700
Mailing Address - Country:US
Mailing Address - Phone:209-551-0420
Mailing Address - Fax:209-551-1665
Practice Address - Street 1:1908 COFFEE RD STE 3
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355
Practice Address - Country:US
Practice Address - Phone:209-846-9429
Practice Address - Fax:209-551-1665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-07
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
1447338355OtherNPI
1225073307OtherNPI