Basic Information
| Provider Information | |||||||||
| NPI: | 1447521745 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF FRESNO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4441 E KINGS CANYON RD | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937023604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596009193 | ||||||||
| FaxNumber: | 5592539144 | ||||||||
| Practice Location | |||||||||
| Address1: | 3133 N MILLBROOK AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937031425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596008918 | ||||||||
| FaxNumber: | 5594535099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2012 | ||||||||
| LastUpdateDate: | 01/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5596009193 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 000001007 | CA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 000001007 | 05 | CA | MEDICAID |