Healthcare Provider Details

I. General information

NPI: 1184680019
Provider Name (Legal Business Name): ELLIOT BEACH CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 07/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4686 N 1ST ST
FRESNO CA
93726-0903
US

IV. Provider business mailing address

4686 N 1ST ST
FRESNO CA
93726-0903
US

V. Phone/Fax

Practice location:
  • Phone: 559-227-9509
  • Fax: 559-227-2737
Mailing address:
  • Phone: 559-227-9509
  • Fax: 559-227-2737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3899
License Number StateCA

VIII. Authorized Official

Name: DR. PREM KRISH
Title or Position: PRESIDENT
Credential: PHD
Phone: 559-227-9509