Healthcare Provider Details

I. General information

NPI: 1093074221
Provider Name (Legal Business Name): EXCELLENCE MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 03/03/2022
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 N. IRWIN ST
HANFORD CA
93230-3813
US

IV. Provider business mailing address

755 N. IRWIN ST
HANFORD CA
93230-3813
US

V. Phone/Fax

Practice location:
  • Phone: 559-585-1200
  • Fax: 844-570-7675
Mailing address:
  • Phone: 559-585-1200
  • Fax: 844-570-7675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberA34991
License Number StateCA

VIII. Authorized Official

Name: RONNETTE DENISE DAULTON
Title or Position: OWNER
Credential: FNP
Phone: 559-585-1200