Provider Demographics
NPI:1194746248
Name:ULTIMATE LIVING MEDICAL CLINIC, PROF. CORP.
Entity type:Organization
Organization Name:ULTIMATE LIVING MEDICAL CLINIC, PROF. CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:WORK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-435-8000
Mailing Address - Street 1:1660 E HERNDON AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3359
Mailing Address - Country:US
Mailing Address - Phone:559-435-8000
Mailing Address - Fax:559-380-2879
Practice Address - Street 1:1660 E HERNDON AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3359
Practice Address - Country:US
Practice Address - Phone:559-435-8000
Practice Address - Fax:559-380-2879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66593207QA0505X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ07640ZMedicare PIN