=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659593135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN JOAQUIN VALLEY COLLEGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8400 W. MINERAL KING
-----------------------------------------------------
City | VISALIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-651-1617
-----------------------------------------------------
Fax | 559-651-0340
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3828 W. CALDWELL AVE.
-----------------------------------------------------
City | VISALIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-734-9000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF ADMINISTRATION
-----------------------------------------------------
Name | MRS. WENDY MENDES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 559-734-9000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------