Provider Demographics
NPI:1114056538
Name:SAIRWAA T. PREVOST, M.D., INC.
Entity Type:Organization
Organization Name:SAIRWAA T. PREVOST, M.D., INC.
Other - Org Name:AGE RIGHT WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAIRWAA
Authorized Official - Middle Name:TANDEE
Authorized Official - Last Name:PREVOST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-489-3312
Mailing Address - Street 1:1400 E TAHQUITZ CANYON WAY
Mailing Address - Street 2:ROOM 323
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-6722
Mailing Address - Country:US
Mailing Address - Phone:646-489-2212
Mailing Address - Fax:
Practice Address - Street 1:35400 BOB HOPE DR
Practice Address - Street 2:SUITE 107
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-1772
Practice Address - Country:US
Practice Address - Phone:646-489-3312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51315207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty