1548689615 NPI number — DESERT INTEGRATIVE MEDICAL CENTER

Table of content: (NPI 1548689615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548689615 NPI number — DESERT INTEGRATIVE MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESERT INTEGRATIVE MEDICAL CENTER
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:
1548689615
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
41865 BOARDWALK
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
PALM DESERT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92211-9026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-340-2260
Provider Business Mailing Address Fax Number:
760-341-5051

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41865 BOARDWALK
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
PALM DESERT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92211-9026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-340-2260
Provider Business Practice Location Address Fax Number:
760-341-5051
Provider Enumeration Date:
04/15/2014

Additional Information

Authorized Official

Authorized Official Last Name:
IZATT
Authorized Official First Name:
NICOLAS
Authorized Official Middle Name:
Z
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
800-214-8618

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , 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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