Healthcare Provider Details

I. General information

NPI: 1609795491
Provider Name (Legal Business Name): MANUEL HERNANDEZ SUDRC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4576 E SHIELDS AVE
FRESNO CA
93726-7220
US

IV. Provider business mailing address

6035 W BABCOCK CT
VISALIA CA
93291-9777
US

V. Phone/Fax

Practice location:
  • Phone: 559-240-9206
  • Fax:
Mailing address:
  • Phone: 559-697-1822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: