Healthcare Provider Details

I. General information

NPI: 1235837857
Provider Name (Legal Business Name): MAXIMINO JAMISOLA DECORION II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2023
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 S A ST
MADERA CA
93638-3806
US

IV. Provider business mailing address

444 W TRENTON AVE
CLOVIS CA
93619-0409
US

V. Phone/Fax

Practice location:
  • Phone: 559-673-9228
  • Fax:
Mailing address:
  • Phone: 559-618-9898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number49890
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: