Healthcare Provider Details

I. General information

NPI: 1104380070
Provider Name (Legal Business Name): CANDACE ANDREA HADDOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2019
Last Update Date: 01/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 VALLEY CHILDRENS PL
MADERA CA
93636-8761
US

IV. Provider business mailing address

9439 N SAYBROOK DR APT 210
FRESNO CA
93720-0636
US

V. Phone/Fax

Practice location:
  • Phone: 559-353-7290
  • Fax: 559-353-7286
Mailing address:
  • Phone: 604-619-2209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberA160473
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: