Healthcare Provider Details

I. General information

NPI: 1306018452
Provider Name (Legal Business Name): KELLEEN BOSCH DO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1374 E ALLUVIAL AVE
FRESNO CA
93720-2608
US

IV. Provider business mailing address

1374 E ALLUVIAL AVE
FRESNO CA
93720-2608
US

V. Phone/Fax

Practice location:
  • Phone: 559-981-2600
  • Fax: 559-981-2610
Mailing address:
  • Phone: 559-981-2600
  • Fax: 559-981-2610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number20A9211
License Number StateCA

VIII. Authorized Official

Name: MRS. MARY KATHLEEN HANSEN
Title or Position: ADMINISTRATOR
Credential:
Phone: 559-981-2600