Basic Information
Provider Information | |||||||||
NPI: | 1962752626 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DESERT/MOUNTAIN CHILDREN'S CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17800 US HIGHWAY 18 | ||||||||
Address2: |   | ||||||||
City: | APPLE VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 923071221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7602426333 | ||||||||
FaxNumber: | 7609460819 | ||||||||
Practice Location | |||||||||
Address1: | 17800 US HIGHWAY 18 | ||||||||
Address2: |   | ||||||||
City: | APPLE VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 923071221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7602426333 | ||||||||
FaxNumber: | 7609460819 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/10/2012 | ||||||||
LastUpdateDate: | 09/10/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POWELL | ||||||||
AuthorizedOfficialFirstName: | RONALD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 7302426333 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PH.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QS1000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
No ID Information.