Healthcare Provider Details

I. General information

NPI: 1124422258
Provider Name (Legal Business Name): GAVIN HARRIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 10/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 N OLIVE AVE
TURLOCK CA
95382-2568
US

IV. Provider business mailing address

1205 N QUINCY RD
TURLOCK CA
95380-2911
US

V. Phone/Fax

Practice location:
  • Phone: 209-667-5600
  • Fax:
Mailing address:
  • Phone: 209-202-4994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: