Healthcare Provider Details

I. General information

NPI: 1194746248
Provider Name (Legal Business Name): ULTIMATE LIVING MEDICAL CLINIC, PROF. CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 10/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 E HERNDON AVE SUITE 101
FRESNO CA
93720-3359
US

IV. Provider business mailing address

1660 E HERNDON AVE SUITE 101
FRESNO CA
93720-3359
US

V. Phone/Fax

Practice location:
  • Phone: 559-435-8000
  • Fax: 559-380-2879
Mailing address:
  • Phone: 559-435-8000
  • Fax: 559-380-2879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberA66593
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberA66593
License Number StateCA

VIII. Authorized Official

Name: DR. WILLIAM RALPH WORK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 559-435-8000