Healthcare Provider Details

I. General information

NPI: 1588079545
Provider Name (Legal Business Name): CENTRAL CALIFORNIA ASTHMA COLLABORATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2014
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1939 N GATEWAY BLVD SUITE 103
FRESNO CA
93727
US

IV. Provider business mailing address

1939 N GATEWAY BLVD SUITE 103
FRESNO CA
93727
US

V. Phone/Fax

Practice location:
  • Phone: 559-272-4874
  • Fax: 559-492-3802
Mailing address:
  • Phone: 559-272-4874
  • Fax: 559-492-3802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: TIM TYNER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 559-272-4874