1275691883 NPI number — YUCCA VALLEY FAMILY MEDICAL ASSOCIATES, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275691883 NPI number — YUCCA VALLEY FAMILY MEDICAL ASSOCIATES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YUCCA VALLEY FAMILY MEDICAL ASSOCIATES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275691883
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
57463 29 PALMS HWY
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
YUCCA VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92284-2925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-228-1855
Provider Business Mailing Address Fax Number:
760-228-1897

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
57463 29 PALMS HWY
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
YUCCA VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92284-2925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-228-1855
Provider Business Practice Location Address Fax Number:
760-228-1897
Provider Enumeration Date:
12/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
ELDENE
Authorized Official Middle Name:
ARNE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
760-228-1855

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  A38944 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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