Healthcare Provider Details

I. General information

NPI: 1932353166
Provider Name (Legal Business Name): SUNNYSIDE MEDICAL CLINIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2008
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5561 E KINGS CANYON RD
FRESNO CA
93727-4528
US

IV. Provider business mailing address

5561 E KINGS CANYON RD
FRESNO CA
93727-4528
US

V. Phone/Fax

Practice location:
  • Phone: 559-255-0496
  • Fax: 559-253-0510
Mailing address:
  • Phone: 559-255-0496
  • Fax: 559-253-0510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberG73482
License Number StateCA

VIII. Authorized Official

Name: DR. JOSE LOPEZ IBARRA
Title or Position: MEDICAL PROVIDER
Credential: M.D
Phone: 559-255-0496