Healthcare Provider Details

I. General information

NPI: 1306310164
Provider Name (Legal Business Name): SANT KUMAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2019
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3621 GLENCREST DR
MODESTO CA
95355-8431
US

IV. Provider business mailing address

PO BOX 4978
MODESTO CA
95352-4978
US

V. Phone/Fax

Practice location:
  • Phone: 209-575-4575
  • Fax: 209-575-4598
Mailing address:
  • Phone: 209-575-4575
  • Fax: 209-575-4598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License NumberRHF20122
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: