Healthcare Provider Details

I. General information

NPI: 1760046569
Provider Name (Legal Business Name): JIMMY LEE COLMENRO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2019
Last Update Date: 04/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

496 S BARTON AVE
FRESNO CA
93702-2985
US

IV. Provider business mailing address

2739 EVERGREEN ST
SELMA CA
93662-4413
US

V. Phone/Fax

Practice location:
  • Phone: 559-860-4422
  • Fax:
Mailing address:
  • Phone: 559-864-2414
  • 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: