Healthcare Provider Details

I. General information

NPI: 1902061815
Provider Name (Legal Business Name): KETSANA VILAYSANE MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6183 N FRESNO ST STE 101
FRESNO CA
93710-8611
US

IV. Provider business mailing address

6183 N FRESNO ST STE 101
FRESNO CA
93710-8611
US

V. Phone/Fax

Practice location:
  • Phone: 559-432-5003
  • Fax: 559-432-5008
Mailing address:
  • Phone: 559-432-5003
  • Fax: 559-432-5008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KETSANA VILAYSANE
Title or Position: PRESIDENT
Credential: M.D
Phone: 559-432-5003