Healthcare Provider Details

I. General information

NPI: 1326358813
Provider Name (Legal Business Name): PDR-PROMESA DEPENDENCY & REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2010
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 N DOUTY ST
HANFORD CA
93230-3912
US

IV. Provider business mailing address

PO BOX 1161
HANFORD CA
93232-1161
US

V. Phone/Fax

Practice location:
  • Phone: 559-584-9033
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberOP10-0184
License Number StateCA

VIII. Authorized Official

Name: CINDY GONZALES
Title or Position: PROGRAM ADMINISTRATOR
Credential:
Phone: 559-584-9033