Healthcare Provider Details

I. General information

NPI: 1265046395
Provider Name (Legal Business Name): RIVERWAY MEDICAL GROUP A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2020
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1827 S COURT ST STE B
VISALIA CA
93277-5469
US

IV. Provider business mailing address

PO BOX 1511
VISALIA CA
93279-1511
US

V. Phone/Fax

Practice location:
  • Phone: 559-260-6509
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JARED WILLIAMS
Title or Position: OWNER
Credential: NP
Phone: 559-372-7390