Basic Information
| Provider Information | |||||||||
| NPI: | 1154895589 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRADO | ||||||||
| FirstName: | IVAN | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2906 SECRETARIAT DR | ||||||||
| Address2: | |||||||||
| City: | ATWATER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953012534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097612125 | ||||||||
| FaxNumber: | 2093941326 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953341257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094462771 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2019 | ||||||||
| LastUpdateDate: | 01/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174H00000X | Y | Other Service Providers | Health Educator |
No ID Information.