Healthcare Provider Details

I. General information

NPI: 1750646410
Provider Name (Legal Business Name): CAROL J MOHAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 08/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

568 E HERNDON AVE SUITE 201
FRESNO CA
93720-2989
US

IV. Provider business mailing address

568 E HERNDON AVE SUITE 201
FRESNO CA
93720-2989
US

V. Phone/Fax

Practice location:
  • Phone: 559-228-6600
  • Fax: 559-226-3709
Mailing address:
  • Phone: 559-228-6600
  • Fax: 559-226-3709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number611261
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: