1760550701 NPI number — DATE PALM INC.

Table of content: (NPI 1760550701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760550701 NPI number — DATE PALM INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DATE PALM 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:
1760550701
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
604 E HOBSONWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLYTHE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92225-1739
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-922-3644
Provider Business Mailing Address Fax Number:
760-922-2671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
604 E HOBSONWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLYTHE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92225-1739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-922-3644
Provider Business Practice Location Address Fax Number:
760-922-2671
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SPELSBERG
Authorized Official First Name:
WALTER
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
OFFICER
Authorized Official Telephone Number:
760-922-3644

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  C22232 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207W00000X , with the licence number: C22232 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: GR0077770 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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