Healthcare Provider Details

I. General information

NPI: 1366855025
Provider Name (Legal Business Name): JETHRO MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2142 N FINE AVE
FRESNO CA
93727-1513
US

IV. Provider business mailing address

2142 N. FINE AVE.
FRESNO CA
93727-1513
US

V. Phone/Fax

Practice location:
  • Phone: 559-307-3342
  • Fax: 559-494-4900
Mailing address:
  • Phone: 559-494-4900
  • Fax: 559-494-4900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL BERNARDONI
Title or Position: PRESIDENT
Credential:
Phone: 559-494-4900