Provider Demographics
NPI:1952109084
Name:PROVERI FRESNO LLC
Entity type:Organization
Organization Name:PROVERI FRESNO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TIGER
Authorized Official - Middle Name:
Authorized Official - Last Name:SAELEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-294-8285
Mailing Address - Street 1:2350 W SHAW AVE STE 126
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3400
Mailing Address - Country:US
Mailing Address - Phone:209-294-8285
Mailing Address - Fax:
Practice Address - Street 1:2350 W SHAW AVE STE 126
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3400
Practice Address - Country:US
Practice Address - Phone:209-294-8285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-05
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy