Basic Information
| Provider Information | |||||||||
| NPI: | 1275670960 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PACKARD | ||||||||
| FirstName: | RAE | ||||||||
| MiddleName: | F | ||||||||
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| Mailing Information | |||||||||
| Address1: | 58967 BUSINESS CENTER DRIVE, | ||||||||
| Address2: | #H | ||||||||
| City: | YUCCA VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602289657 | ||||||||
| FaxNumber: | 7603696758 | ||||||||
| Practice Location | |||||||||
| Address1: | 58967 BUSINESS CENTER DRIVE, | ||||||||
| Address2: | #H | ||||||||
| City: | YUCCA VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602289657 | ||||||||
| FaxNumber: | 7603696758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 10/22/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.