Healthcare Provider Details

I. General information

NPI: 1265521488
Provider Name (Legal Business Name): GREATER FRESNO HEALTH ORGANIZATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4929 E KINGS CANYON RD
FRESNO CA
93727-3812
US

IV. Provider business mailing address

4929 E KINGS CANYON RD
FRESNO CA
93727-3812
US

V. Phone/Fax

Practice location:
  • Phone: 559-255-6476
  • Fax: 559-255-7906
Mailing address:
  • Phone: 559-255-6476
  • Fax: 559-255-7906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number04000036
License Number StateCA

VIII. Authorized Official

Name: MR. BLA MOUANOUTOUA
Title or Position: CEO
Credential:
Phone: 559-255-6476