Provider Demographics
NPI:1952872533
Name:FANDIALAN, PROLAN ROBLES
Entity Type:Individual
Prefix:
First Name:PROLAN
Middle Name:ROBLES
Last Name:FANDIALAN
Suffix:
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 1:9706 HARVEY CT
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93312-2829
Mailing Address - Country:US
Mailing Address - Phone:661-717-2006
Mailing Address - Fax:800-268-1798
Practice Address - Street 1:9706 HARVEY CT
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93312-2829
Practice Address - Country:US
Practice Address - Phone:661-717-2006
Practice Address - Fax:800-268-1798
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA157201805310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility