Healthcare Provider Details

I. General information

NPI: 1689076846
Provider Name (Legal Business Name): MR. JAMES EASLEY JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 CLEMENT ST
SAN FRANCISCO CA
94121-1545
US

IV. Provider business mailing address

1395 N LINCOLN ST APT 913
DIXON CA
95620-9248
US

V. Phone/Fax

Practice location:
  • Phone: 415-221-4810
  • Fax:
Mailing address:
  • Phone: 707-853-1072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: