Healthcare Provider Details

I. General information

NPI: 1073977526
Provider Name (Legal Business Name): ALFRED MEDINA R1215080915
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 04/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 BERNARD ST
BAKERSFIELD CA
93305-3018
US

IV. Provider business mailing address

504 BERNARD ST
BAKERSFIELD CA
93305-3018
US

V. Phone/Fax

Practice location:
  • Phone: 661-637-2187
  • Fax: 661-326-1342
Mailing address:
  • Phone: 661-637-2187
  • Fax: 661-326-1342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1215080915
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: