Healthcare Provider Details

I. General information

NPI: 1740800531
Provider Name (Legal Business Name): CLEVELAND ANTHONY THIBODEAUX III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 COURAGE DR
FAIRFIELD CA
94533-6717
US

IV. Provider business mailing address

1966 FINCH WAY
FAIRFIELD CA
94533-2312
US

V. Phone/Fax

Practice location:
  • Phone: 707-428-1131
  • Fax:
Mailing address:
  • Phone: 707-389-1563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: