Basic Information
Provider Information | |||||||||
NPI: | 1023394285 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DESERT VIEW MEDICAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 205 N 1ST ST STE A | ||||||||
Address2: |   | ||||||||
City: | BLYTHE | ||||||||
State: | CA | ||||||||
PostalCode: | 922251777 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7609213474 | ||||||||
FaxNumber: | 7609213471 | ||||||||
Practice Location | |||||||||
Address1: | 205 N 1ST ST STE A | ||||||||
Address2: |   | ||||||||
City: | BLYTHE | ||||||||
State: | CA | ||||||||
PostalCode: | 922251777 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7609213474 | ||||||||
FaxNumber: | 7609213471 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2011 | ||||||||
LastUpdateDate: | 08/05/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LUCERO | ||||||||
AuthorizedOfficialFirstName: | KENNETH | ||||||||
AuthorizedOfficialMiddleName: | G. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7609213468 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G60508 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.