Healthcare Provider Details

I. General information

NPI: 1528797958
Provider Name (Legal Business Name): RUSSELL CHARLES SERDA PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RUSSELL CHARLES WESLEY JR.

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 06/10/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 KING AVE
CORCORAN CA
93212-9611
US

IV. Provider business mailing address

39711 CLOVER LN
SQUAW VALLEY CA
93675-8703
US

V. Phone/Fax

Practice location:
  • Phone: 559-992-7100
  • Fax:
Mailing address:
  • Phone: 858-527-8056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: