Healthcare Provider Details

I. General information

NPI: 1316322647
Provider Name (Legal Business Name): STATE OF CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2015
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21633 AVENUE 24
CHOWCHILLA CA
93610-9650
US

IV. Provider business mailing address

21633 AVENUE 24
CHOWCHILLA CA
93610-9650
US

V. Phone/Fax

Practice location:
  • Phone: 559-665-6100
  • Fax: 559-665-6586
Mailing address:
  • Phone: 559-665-6100
  • Fax: 559-665-6586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2400X
TaxonomyPrison Health Clinic/Center
License NumberLCF 45081
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License NumberLCF 45081
License Number StateCA

VIII. Authorized Official

Name: DR. FRANCISCO LOPEZ
Title or Position: PHARMACIST II
Credential: PHARM.D.
Phone: 559-665-6100