# MODESTO NEONATAL MEDICAL GROUP, INC.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1912197294
- **Authorized official:** MRS. GINA WALLACE (BILLING AGENT)
- **Authorized official phone:** (209) 571-8330

## Contact information

- **Practice address:** 1441 FLORIDA AVE, MODESTO, CA 95350-4405
- **Practice address phone:** (209) 571-8330
- **Mailing address:** PO BOX 577558, MODESTO, CA 95357-7558
- **Mailing address phone:** (209) 571-8330
- **Mailing address fax:** (209) 491-7184

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2080N0001X | Neonatal-Perinatal Medicine Physician | 39491 | CA | Yes |

## Other

- **Enumeration date:** 08/01/2007
- **Last updated:** 08/01/2007