Provider Demographics
NPI:1013108752
Name:MEDICOS UNIDOS DE AVENAL
Entity Type:Organization
Organization Name:MEDICOS UNIDOS DE AVENAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOMAS
Authorized Official - Middle Name:BALLESTEROS
Authorized Official - Last Name:RIOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-386-9000
Mailing Address - Street 1:PO BOX 530
Mailing Address - Street 2:
Mailing Address - City:LEMOORE
Mailing Address - State:CA
Mailing Address - Zip Code:93245-0530
Mailing Address - Country:US
Mailing Address - Phone:559-386-9000
Mailing Address - Fax:
Practice Address - Street 1:148 E KINGS ST
Practice Address - Street 2:
Practice Address - City:AVENAL
Practice Address - State:CA
Practice Address - Zip Code:93204-1529
Practice Address - Country:US
Practice Address - Phone:559-386-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM058905FMedicaid
CA058905Medicare Oscar/Certification