Healthcare Provider Details

I. General information

NPI: 1538346531
Provider Name (Legal Business Name): MADERA FAMILY MEDICAL GROUP LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W 4TH ST
MADERA CA
93637-4474
US

IV. Provider business mailing address

1111 W 4TH ST
MADERA CA
93637-4474
US

V. Phone/Fax

Practice location:
  • Phone: 559-673-3000
  • Fax: 559-662-2910
Mailing address:
  • Phone: 559-673-3000
  • Fax: 559-662-2910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberCLF11180
License Number StateCA

VIII. Authorized Official

Name: AFTAB A NAZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 559-673-3000