Healthcare Provider Details

I. General information

NPI: 1790042372
Provider Name (Legal Business Name): KEVIN C CARREIRO RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 04/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 M ST
FRESNO CA
93721
US

IV. Provider business mailing address

1225 M ST
FRESNO CA
93721-1805
US

V. Phone/Fax

Practice location:
  • Phone: 559-600-9365
  • Fax:
Mailing address:
  • Phone: 559-600-9365
  • Fax: 559-488-3298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN821495
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number198801
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: