Provider Demographics
NPI:1588434849
Name:POTENTIAL WAY
Entity type:Organization
Organization Name:POTENTIAL WAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:916-613-0098
Mailing Address - Street 1:PO BOX 516
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95423-0516
Mailing Address - Country:US
Mailing Address - Phone:916-613-0098
Mailing Address - Fax:
Practice Address - Street 1:12901 E HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:CLEARLAKE OAKS
Practice Address - State:CA
Practice Address - Zip Code:95423-9326
Practice Address - Country:US
Practice Address - Phone:916-613-0098
Practice Address - Fax:707-703-5792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging
No251E00000XAgenciesHome Health
No174200000XOther Service ProvidersMeals
No251B00000XAgenciesCase Management