Healthcare Provider Details

I. General information

NPI: 1386850998
Provider Name (Legal Business Name): JUAN ALFREDO BEDOLLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JUAN ALFREDO BEDOLLA

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 O ST STE 302
FRESNO CA
93721-1828
US

IV. Provider business mailing address

PO BOX 25042
FRESNO CA
93729-5042
US

V. Phone/Fax

Practice location:
  • Phone: 559-369-4625
  • Fax: 559-369-7259
Mailing address:
  • Phone: 559-369-4625
  • Fax: 559-693-7259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95059739
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95005969
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95059739
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: