Provider Demographics
NPI:1386410652
Name:BEDOLLA, ERNESTO ALEXANDER (N/A)
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:ALEXANDER
Last Name:BEDOLLA
Suffix:
Gender:M
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21997 AVENUE 176
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-9272
Mailing Address - Country:US
Mailing Address - Phone:559-542-8088
Mailing Address - Fax:
Practice Address - Street 1:21997 AVENUE 176
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-9272
Practice Address - Country:US
Practice Address - Phone:559-542-8088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY1601235106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician