Healthcare Provider Details

I. General information

NPI: 1548814171
Provider Name (Legal Business Name): JESUS ZAVALA RAMIREZ SUDRC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2019
Last Update Date: 07/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

637 BROADWAY ST
KING CITY CA
93930-3231
US

IV. Provider business mailing address

637 BROADWAY ST
KING CITY CA
93930-3231
US

V. Phone/Fax

Practice location:
  • Phone: 831-525-8101
  • Fax: 831-525-8130
Mailing address:
  • Phone: 831-525-8101
  • Fax: 831-525-8130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCADPT9611
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: