Healthcare Provider Details

I. General information

NPI: 1003019282
Provider Name (Legal Business Name): RONALD D FILLMORE CRNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2776 PACIFIC AVE PACIFIC HOSPITAL OF LONG BEACH
LONG BEACH CA
90806-2613
US

IV. Provider business mailing address

PO BOX 6580
LONG BEACH CA
90806-6580
US

V. Phone/Fax

Practice location:
  • Phone: 760-534-9550
  • Fax: 951-808-9700
Mailing address:
  • Phone: 760-534-9550
  • Fax: 951-808-9700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number305990
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: