Healthcare Provider Details

I. General information

NPI: 1164235388
Provider Name (Legal Business Name): CENTRAL VALLEY COMMUNITY SPORTS FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2025
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 N CEDAR AVE
FRESNO CA
93726-5267
US

IV. Provider business mailing address

4266 N COLLEGE AVE
FRESNO CA
93704-3844
US

V. Phone/Fax

Practice location:
  • Phone: 559-349-6965
  • Fax: 707-703-5794
Mailing address:
  • Phone: 559-349-6965
  • Fax: 707-703-5794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. TERANCE FRAZIER
Title or Position: PRESIDENT
Credential:
Phone: 559-349-6965