Healthcare Provider Details

I. General information

NPI: 1679681670
Provider Name (Legal Business Name): JACK L. GUCCIONE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 11/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 NEWBURG RD
FORTUNA CA
95540-2818
US

IV. Provider business mailing address

2404 NEWBURG RD
FORTUNA CA
95540-2818
US

V. Phone/Fax

Practice location:
  • Phone: 707-725-8770
  • Fax: 707-725-8773
Mailing address:
  • Phone: 707-725-8770
  • Fax: 707-725-8773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG66333
License Number StateCA

VIII. Authorized Official

Name: DR. JACK L. GUCCIONE
Title or Position: DIRECTOR
Credential: MD, MPH
Phone: 707-725-8770