Healthcare Provider Details

I. General information

NPI: 1629200837
Provider Name (Legal Business Name): SEVERO ROSALES JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 08/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3467 W SHAW AVE SUITE # 102
FRESNO CA
93711-3223
US

IV. Provider business mailing address

404 FIG ST
MADERA CA
93638-3420
US

V. Phone/Fax

Practice location:
  • Phone: 559-274-0299
  • Fax: 559-244-0328
Mailing address:
  • Phone: 559-232-3870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: