Facts
- Status
- A
- Type
- Individual
- Enumeration date
- 2021-08-23
- Last updated
- 2023-11-16
Specialties
Licenses
- License CA
- 117676
Location
- Practice location
- 516 N KAWEAH AVE
- City
- EXETER CA
- Postal code
- 932211200
- Phone
- 559-594-4969
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.