Basic Information
| Provider Information | |||||||||
| NPI: | 1760761498 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ACOSTA | ||||||||
| FirstName: | GILBERT | ||||||||
| MiddleName: | VICTOR | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 58945 BUSINESS CENTER DR STE D | ||||||||
| Address2: | |||||||||
| City: | YUCCA VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922847310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602289657 | ||||||||
| FaxNumber: | 7603696758 | ||||||||
| Practice Location | |||||||||
| Address1: | 58945 BUSINESS CENTER DR STE D | ||||||||
| Address2: | |||||||||
| City: | YUCCA VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922847310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602289657 | ||||||||
| FaxNumber: | 7603696758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2011 | ||||||||
| LastUpdateDate: | 04/23/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.