Healthcare Provider Details

I. General information

NPI: 1790232809
Provider Name (Legal Business Name): FIDENCIO CUEVAS A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 5TH STREET
GONZALES CA
93926
US

IV. Provider business mailing address

PO BOX 446
GONZALES CA
93926-0446
US

V. Phone/Fax

Practice location:
  • Phone: 559-351-5927
  • Fax:
Mailing address:
  • Phone: 559-351-5927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: