Provider Demographics
NPI:1659253409
Name:ALCANTARA, ALBERT ARIEL
Entity type:Individual
Prefix:
First Name:ALBERT ARIEL
Middle Name:
Last Name:ALCANTARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 VICENZA DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-3823
Mailing Address - Country:US
Mailing Address - Phone:350-204-2266
Mailing Address - Fax:
Practice Address - Street 1:2401 E ORANGEBURG AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3351
Practice Address - Country:US
Practice Address - Phone:209-417-0949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-23
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86329220133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered