Healthcare Provider Details

I. General information

NPI: 1689857609
Provider Name (Legal Business Name): PAO GE LOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2007
Last Update Date: 12/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4552 MEADOW WAY
OLIVEHURST CA
95961-4527
US

IV. Provider business mailing address

4552 MEADOW WAY
OLIVEHURST CA
95961-4527
US

V. Phone/Fax

Practice location:
  • Phone: 530-742-7769
  • Fax:
Mailing address:
  • Phone: 530-742-7769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number004274
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: