Healthcare Provider Details

I. General information

NPI: 1750851572
Provider Name (Legal Business Name): TRENTON EDWARD KIDDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 E KINGS CANYON RD # 319
FRESNO CA
93702-3604
US

IV. Provider business mailing address

2238 N DE WOLF AVE
FRESNO CA
93737-9553
US

V. Phone/Fax

Practice location:
  • Phone: 559-600-2382
  • Fax:
Mailing address:
  • Phone: 559-878-1658
  • 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: