=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588978944
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SMITA NAGAVALLI OWNER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2010
-----------------------------------------------------
Last Update Date | 10/06/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3456 N CACTUS CT
-----------------------------------------------------
City | HANFORD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93230-8300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-582-1111
-----------------------------------------------------
Fax | 559-410-8737
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3456 N CACTUS CT
-----------------------------------------------------
City | HANFORD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93230-8300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-582-1111
-----------------------------------------------------
Fax | 559-410-8737
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172A00000X
-----------------------------------------------------
Taxonomy Name | Driver
-----------------------------------------------------
License Number | D7120793
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------