Healthcare Provider Details

I. General information

NPI: 1578331153
Provider Name (Legal Business Name): PREMIUM ALLERGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2023
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1069 E CHAMPLAIN DR STE A
FRESNO CA
93720-4223
US

IV. Provider business mailing address

2021 HERNDON AVE STE 201
CLOVIS CA
93611-6317
US

V. Phone/Fax

Practice location:
  • Phone: 559-387-5230
  • Fax: 559-900-7952
Mailing address:
  • Phone: 559-387-5230
  • Fax: 559-900-7952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: SONYA LEAL
Title or Position: MANAGER
Credential:
Phone: 559-387-5230