1730936642 NPI number — MR. BROCK DEVERE CARTER JENIKOVSKY CADC-II, ICADC

Table of content: MR. BROCK DEVERE CARTER JENIKOVSKY CADC-II, ICADC (NPI 1730936642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730936642 NPI number — MR. BROCK DEVERE CARTER JENIKOVSKY CADC-II, ICADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENIKOVSKY
Provider First Name:
BROCK
Provider Middle Name:
DEVERE CARTER
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CADC-II, ICADC
Provider Gender Code:
M

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:
1730936642
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
51165 EISENHOWER DR APT B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA QUINTA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92253-3084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-883-7441
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44359 PALM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92201-3116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-342-6616
Provider Business Practice Location Address Fax Number:
760-347-8276
Provider Enumeration Date:
04/30/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  A051980920 , 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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