Healthcare Provider Details

I. General information

NPI: 1770140600
Provider Name (Legal Business Name): KELLY MARIE FOREMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2019
Last Update Date: 05/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W HOSPITAL RD
FRENCH CAMP CA
95231-9693
US

IV. Provider business mailing address

500 W HOSPITAL RD
FRENCH CAMP CA
95231-9693
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-6013
  • Fax: 209-468-7032
Mailing address:
  • Phone: 209-468-6013
  • Fax: 209-468-7032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number390002EN
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: