Healthcare Provider Details

I. General information

NPI: 1407554595
Provider Name (Legal Business Name): EUGENE GARRETT CCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 02/20/2023
Certification Date: 02/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 YULUPA AVE
SANTA ROSA CA
95405-5108
US

IV. Provider business mailing address

1500 STANDIFORD AVE BLDG C
MODESTO CA
95350-0592
US

V. Phone/Fax

Practice location:
  • Phone: 808-349-6706
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: