MEDICARE: DINO PEREZ RAS 1

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609151463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DINO PEREZ RAS 1

Provider Business Mailing Address
First Line	:	7475 N PALM AVE STE 107
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93711-5763
Country	:	US
Telephone Number	:	559-981-5534
Fax Number	:	559-981-5539

Provider Business Practice Location Address
First Line	:	2910 E OLIVE AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93701-1223
Country	:	US
Telephone Number	:	559-981-5534
Fax Number	:	559-981-5539

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2011
Last Update Date	:	10/12/2011

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