Healthcare Provider Details

I. General information

NPI: 1407163777
Provider Name (Legal Business Name): ROY L BUFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 M ST
FRESNO CA
93721-1808
US

IV. Provider business mailing address

114 E SHAW AVE STE 210
FRESNO CA
93710-7621
US

V. Phone/Fax

Practice location:
  • Phone: 559-264-2700
  • Fax: 559-264-2767
Mailing address:
  • Phone: 559-221-8100
  • Fax: 559-221-8101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC055710518
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: