Healthcare Provider Details

I. General information

NPI: 1467785485
Provider Name (Legal Business Name): JESUS ALFREDO SERRATO VIDAL ASW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 10/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83912 AVENUE 45 STE 9
INDIO CA
92201-3338
US

IV. Provider business mailing address

3525 PRESLEY AVE
RIVERSIDE CA
92507-4453
US

V. Phone/Fax

Practice location:
  • Phone: 603-470-7547
  • Fax:
Mailing address:
  • Phone: 951-782-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: