Basic Information
| Provider Information | |||||||||
| NPI: | 1356777890 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DESERT MEDICAL GROUP, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | YUCCA VALLEY IMMEDIATE CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 275 N EL CIELO RD | ||||||||
| Address2: | |||||||||
| City: | PALM SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922626972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603238657 | ||||||||
| FaxNumber: | 7603189083 | ||||||||
| Practice Location | |||||||||
| Address1: | 57840 29 PALMS HWY | ||||||||
| Address2: | A | ||||||||
| City: | YUCCA VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922843047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603238657 | ||||||||
| FaxNumber: | 7603189083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2013 | ||||||||
| LastUpdateDate: | 09/16/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LECLAIR | ||||||||
| AuthorizedOfficialFirstName: | HELENE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP NETWORK ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 7603238657 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.