Healthcare Provider Details

I. General information

NPI: 1063618296
Provider Name (Legal Business Name): VALLEY NEPHROLOGY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 01/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 E HERNDON AVE SUITE 105
FRESNO CA
93720-3306
US

IV. Provider business mailing address

1313 E HERNDON AVE SUITE 105
FRESNO CA
93720-3306
US

V. Phone/Fax

Practice location:
  • Phone: 559-448-8481
  • Fax: 559-448-0996
Mailing address:
  • Phone: 559-448-8481
  • Fax: 559-448-0996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberG13844
License Number StateCA

VIII. Authorized Official

Name: MRS. LEONOR Q GARBUTT
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 559-448-8481