Healthcare Provider Details

I. General information

NPI: 1639969900
Provider Name (Legal Business Name): RUPINDERPAL S MANGAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2025
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 E CLINTON AVE
FRESNO CA
93703-2223
US

IV. Provider business mailing address

11253 N VIA PALERMO WAY
FRESNO CA
93730-8818
US

V. Phone/Fax

Practice location:
  • Phone: 559-225-6100
  • Fax:
Mailing address:
  • Phone: 559-403-3708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number752554
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: