Healthcare Provider Details

I. General information

NPI: 1336577931
Provider Name (Legal Business Name): FERNANDO BANUELOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2013
Last Update Date: 10/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7225 N 1ST ST STE. 101
FRESNO CA
93720-2986
US

IV. Provider business mailing address

7225 N 1ST ST STE. 101
FRESNO CA
93720-2986
US

V. Phone/Fax

Practice location:
  • Phone: 559-221-8100
  • Fax:
Mailing address:
  • Phone: 559-221-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: