Healthcare Provider Details

I. General information

NPI: 1255602066
Provider Name (Legal Business Name): SYNCHRONY OF VISALIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 N DEMAREE ST
VISALIA CA
93291-4119
US

IV. Provider business mailing address

1041 N DEMAREE ST
VISALIA CA
93291-4119
US

V. Phone/Fax

Practice location:
  • Phone: 559-635-4252
  • Fax: 559-635-4281
Mailing address:
  • Phone: 559-635-4252
  • Fax: 559-635-4281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DR. EDWYN W ORTIZ-NANCE
Title or Position: CLINICAL DIRECTOR
Credential: PSYD.
Phone: 559-635-4252