Provider Demographics
NPI:1629200837
Name:ROSALES, SEVERO JR
Entity Type:Individual
Prefix:
First Name:SEVERO
Middle Name:
Last Name:ROSALES
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 FIG ST
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93638-3420
Mailing Address - Country:US
Mailing Address - Phone:559-232-3870
Mailing Address - Fax:
Practice Address - Street 1:3467 W SHAW AVE
Practice Address - Street 2:SUITE # 102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3223
Practice Address - Country:US
Practice Address - Phone:559-274-0299
Practice Address - Fax:559-244-0328
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator