Healthcare Provider Details

I. General information

NPI: 1548723794
Provider Name (Legal Business Name): SELINA CHAVEZ ROBLES I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 04/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 WOOD ST
EUREKA CA
95501-4413
US

IV. Provider business mailing address

447 SUMMER ST
FORTUNA CA
95540-3052
US

V. Phone/Fax

Practice location:
  • Phone: 707-268-2990
  • Fax:
Mailing address:
  • Phone: 707-382-9184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberE1090805
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: