Healthcare Provider Details

I. General information

NPI: 1700267796
Provider Name (Legal Business Name): PATRICIA BEDOLLLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 06/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 FALL RIVER DR
MODESTO CA
95351-5377
US

IV. Provider business mailing address

820 FALL RIVER DR
MODESTO CA
95351-5377
US

V. Phone/Fax

Practice location:
  • Phone: 209-818-9396
  • Fax:
Mailing address:
  • Phone: 209-818-9396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number270766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: