Healthcare Provider Details

I. General information

NPI: 1669679189
Provider Name (Legal Business Name): THE GOOD NEIGHBOR WALK IN CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 02/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4844 N 1ST ST SUITE 104
FRESNO CA
93726-0529
US

IV. Provider business mailing address

4844 N 1ST ST SUITE 104
FRESNO CA
93726-0529
US

V. Phone/Fax

Practice location:
  • Phone: 559-221-9088
  • Fax: 559-221-9087
Mailing address:
  • Phone: 559-221-9088
  • Fax: 559-221-9087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberA53206
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberA53206
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberRN505630-NP8370
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number00A532060
License Number StateCA

VIII. Authorized Official

Name: DR. THAN A AW
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 559-221-9088