=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760916951
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINERIDGE OBSTETRIX & GYNECOLOGY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2017
-----------------------------------------------------
Last Update Date | 05/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2137 HERNDON AVE SUITE 102
-----------------------------------------------------
City | CLOVIS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93611-6306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-466-7100
-----------------------------------------------------
Fax | 559-466-7102
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2137 HERNDON AVE SUITE 102
-----------------------------------------------------
City | CLOVIS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93611-6306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-466-7100
-----------------------------------------------------
Fax | 559-466-7102
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ISRAEL K. BROWN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 559-466-7100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------