Provider Demographics
NPI:1609439108
Name:GARCIA, ENEDELIA N/A
Entity type:Individual
Prefix:
First Name:ENEDELIA
Middle Name:N/A
Last Name:GARCIA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:ENEDELIA
Other - Middle Name:
Other - Last Name:AGUALLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 SCENIC DR BLDG A
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6131
Mailing Address - Country:US
Mailing Address - Phone:209-525-4982
Mailing Address - Fax:209-558-4332
Practice Address - Street 1:800 SCENIC DR BLDG A
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6131
Practice Address - Country:US
Practice Address - Phone:209-525-4982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-BAMIJO175T00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator