Healthcare Provider Details

I. General information

NPI: 1588708572
Provider Name (Legal Business Name): ANDY POE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 G STREET
SACRAMENTO CA
95814
US

IV. Provider business mailing address

930 G STREET
SACRAMENTO CA
95814
US

V. Phone/Fax

Practice location:
  • Phone: 916-441-2933
  • Fax: 916-441-0286
Mailing address:
  • Phone: 916-441-2933
  • Fax: 916-441-0286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number101Y00000X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: