Provider Demographics
NPI:1427676535
Name:A NEW AWAKENING OF THE SAN JOAQUIN
Entity type:Organization
Organization Name:A NEW AWAKENING OF THE SAN JOAQUIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:CAMPOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-721-9279
Mailing Address - Street 1:2216 E BRANDYWINE LN
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-4656
Mailing Address - Country:US
Mailing Address - Phone:559-721-9279
Mailing Address - Fax:559-481-8426
Practice Address - Street 1:4576 E SHIELDS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-7220
Practice Address - Country:US
Practice Address - Phone:559-579-0935
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:A NEW AWAKENING OF THE SAN JOAQUIN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility