Provider Demographics
NPI:1942294327
Name:CENTRAL VALLEY URGENT CARE MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CENTRAL VALLEY URGENT CARE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-225-4706
Mailing Address - Street 1:199 W SHIELDS AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-4102
Mailing Address - Country:US
Mailing Address - Phone:559-225-4706
Mailing Address - Fax:559-225-4710
Practice Address - Street 1:199 W SHIELDS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93705-4102
Practice Address - Country:US
Practice Address - Phone:559-225-4706
Practice Address - Fax:559-225-4710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ25701ZMedicare ID - Type Unspecified