Organization
POTENTIAL WAY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. JACQUELINE MARIE KELLY RN (CEO)
(916) 613-0098
Entity
Organization
Contact information
Practice address
12901 E HIGHWAY 20, CLEARLAKE OAKS, CA 95423-9326
(916) 613-0098
(707) 703-5792
Mailing address
PO BOX 516, CLEARLAKE OAKS, CA 95423-0516
(916) 613-0098
Taxonomy
Speciality
Code
Description
License number
State
174200000X
Meals Provider
—
—
177F00000X
Lodging Provider
Primary
—
—
251B00000X
Case Management Agency
—
—
251E00000X
Home Health Agency
—
—
Other
Enumeration date
01/08/2024
Last updated
01/08/2024
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