1073898565 NPI number — PROMESA BEHAVIORAL HEALTH

Table of content: (NPI 1073898565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073898565 NPI number — PROMESA BEHAVIORAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROMESA BEHAVIORAL HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073898565
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7475 N PALM AVE STE 107
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93711-5763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-439-5437
Provider Business Mailing Address Fax Number:
559-439-5411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1282 BELMONT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENDOTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93640-2667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-655-1993
Provider Business Practice Location Address Fax Number:
559-655-0223
Provider Enumeration Date:
10/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WEIGANT
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
559-439-5437

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  101044 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1044 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com