Healthcare Provider Details

I. General information

NPI: 1184192601
Provider Name (Legal Business Name): KEANDRE LARON MADKINS-HAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2018
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 TABLE MOUNTAIN BLVD
OROVILLE CA
95965-3578
US

IV. Provider business mailing address

3217 COHASSET RD
CHICO CA
95973-5404
US

V. Phone/Fax

Practice location:
  • Phone: 530-538-7705
  • Fax:
Mailing address:
  • Phone: 530-891-2850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: