Healthcare Provider Details

I. General information

NPI: 1629584073
Provider Name (Legal Business Name): VICENTE JESUS ALFARO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2017
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1343 W MAIN ST STE A&B
MERCED CA
95340-4438
US

IV. Provider business mailing address

7246 REMMET AVE
CANOGA PARK CA
91303-1531
US

V. Phone/Fax

Practice location:
  • Phone: 209-725-1060
  • Fax:
Mailing address:
  • Phone: 800-821-0775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: