Healthcare Provider Details

I. General information

NPI: 1003231523
Provider Name (Legal Business Name): MR. GREGORY AIFEHIENGBE IDONI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2014
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3618 W DAYTON AVE
FRESNO CA
93722-4704
US

IV. Provider business mailing address

3618 W DAYTON AVE
FRESNO CA
93722-4704
US

V. Phone/Fax

Practice location:
  • Phone: 559-275-2488
  • Fax: 559-275-2488
Mailing address:
  • Phone: 559-275-2488
  • Fax: 559-275-2488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number107206634
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: