=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952109084
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVERI FRESNO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2025
-----------------------------------------------------
Last Update Date | 03/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2350 W SHAW AVE STE 126
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93711-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-294-8285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2350 W SHAW AVE STE 126
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93711-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-294-8285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | TIGER SAELEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 209-294-8285
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------