Healthcare Provider Details

I. General information

NPI: 1316674518
Provider Name (Legal Business Name): PALM BLUFFS SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2022
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7766 N PALM AVE # 104
FRESNO CA
93711-5734
US

IV. Provider business mailing address

7766 N PALM AVE STE 104
FRESNO CA
93711-5704
US

V. Phone/Fax

Practice location:
  • Phone: 559-439-5300
  • Fax:
Mailing address:
  • Phone: 559-439-5300
  • Fax: 559-412-2645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JORDAN DAVID PRIETO
Title or Position: OWNER
Credential: DDS
Phone: 559-906-0209