Healthcare Provider Details

I. General information

NPI: 1316261373
Provider Name (Legal Business Name): MEDMARK1
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2010
Last Update Date: 03/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 M ST SAME
FRESNO CA
93721-1808
US

IV. Provider business mailing address

1310 M ST SAME
FRESNO CA
93721-1808
US

V. Phone/Fax

Practice location:
  • Phone: 559-264-2700
  • Fax:
Mailing address:
  • Phone: 559-264-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberB3084739
License Number StateCA

VIII. Authorized Official

Name: MRS. CAROL LYNN RIVAS
Title or Position: COUNSELOR
Credential:
Phone: 559-264-2700