Healthcare Provider Details

I. General information

NPI: 1801349683
Provider Name (Legal Business Name): ARCHANA BANGALORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 W SHAW AVE
CLOVIS CA
93612-3746
US

IV. Provider business mailing address

21890 W COLORADO AVENUE
SAN JOAQUIN CA
93660
US

V. Phone/Fax

Practice location:
  • Phone: 559-203-6600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA157666
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: