Healthcare Provider Details

I. General information

NPI: 1639340003
Provider Name (Legal Business Name): JAMES RAY DEATON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2523 EL PORTAL DR 103
SAN PABLO CA
94806-3305
US

IV. Provider business mailing address

2523 EL PORTAL DR 103
SAN PABLO CA
94806-3305
US

V. Phone/Fax

Practice location:
  • Phone: 510-374-7500
  • Fax:
Mailing address:
  • Phone: 510-374-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number432077
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: