Basic Information
| Provider Information | |||||||||
| NPI: | 1154312619 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DESERT MEDICAL GROUP/LIVING AND AGING WELL | ||||||||
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| OtherOrganizationName: | DESERT OASIS HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 275 N EL CIELO RD | ||||||||
| Address2: | |||||||||
| City: | PALM SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922626972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603204122 | ||||||||
| FaxNumber: | 7603202725 | ||||||||
| Practice Location | |||||||||
| Address1: | 68860 PEREZ RD | ||||||||
| Address2: | |||||||||
| City: | CATHEDRAL CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922347249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603284499 | ||||||||
| FaxNumber: | 7603202725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 11/20/2007 | ||||||||
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| AuthorizedOfficialLastName: | LECLAIR | ||||||||
| AuthorizedOfficialFirstName: | HELENE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7603204122 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207QG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
No ID Information.