Organization
CDCR
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KO BRUCE FANG PH.D. (PSYCHOLOGIST)
(209) 274-4911
Entity
Organization
Contact information
Practice address
4001 HIGHWAY 104, IONE, CA 95640
(209) 274-4911
(209) 274-5147
Mailing address
5215 LOTUS POND WAY, ELK GROVE, CA 95757-4342
(916) 296-5089
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
PSY18841
CA
Other
Enumeration date
11/08/2013
Last updated
11/08/2013
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