Healthcare Provider Details

I. General information

NPI: 1164179610
Provider Name (Legal Business Name): FWDIOP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2022
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2261 VILLA AVE STE 106
CLOVIS CA
93612-4377
US

IV. Provider business mailing address

1111 E HERNDON AVE STE 211
FRESNO CA
93720-3100
US

V. Phone/Fax

Practice location:
  • Phone: 559-355-0089
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SHAUN TUCKER
Title or Position: PROGRAM MANAGER
Credential:
Phone: 559-355-0089