Healthcare Provider Details

I. General information

NPI: 1750658506
Provider Name (Legal Business Name): AGUSTIN VIEYRA ORNELAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2011
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 W HENDERSON AVE STE 2
PORTERVILLE CA
93257-1490
US

IV. Provider business mailing address

1055 W HENDERSON AVE STE 2
PORTERVILLE CA
93257-1490
US

V. Phone/Fax

Practice location:
  • Phone: 559-788-1200
  • Fax:
Mailing address:
  • Phone: 559-801-9521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number112881
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: