Healthcare Provider Details

I. General information

NPI: 1841502655
Provider Name (Legal Business Name): MEDINA RESIDENTICAL CARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2010
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1568 N MILLBROOK AVE
FRESNO CA
93703-4149
US

IV. Provider business mailing address

1568 N MILLBROOK AVE
FRESNO CA
93703-4149
US

V. Phone/Fax

Practice location:
  • Phone: 559-392-7291
  • Fax: 559-840-1714
Mailing address:
  • Phone: 559-392-7291
  • Fax: 559-840-1714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number107202360
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number107202360
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number107203232
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: MYSTI MEDINA
Title or Position: OWNER
Credential:
Phone: 559-392-7291