Healthcare Provider Details

I. General information

NPI: 1881945574
Provider Name (Legal Business Name): MR. DONAHVAUGH DIMARCO REY PRITCHETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2012
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 E SHAWAVE 150
FRESNO CA
93710-8105
US

IV. Provider business mailing address

1630 E SHAW AVE SUITE 150
FRESNO CA
93710-8105
US

V. Phone/Fax

Practice location:
  • Phone: 559-248-8550
  • Fax:
Mailing address:
  • Phone: 559-248-8550
  • 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: