Provider Demographics
NPI:1306409461
Name:MALCOM, CLIFTON DESHAUN
Entity Type:Individual
Prefix:MR
First Name:CLIFTON
Middle Name:DESHAUN
Last Name:MALCOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66659 EL DORADO PL
Mailing Address - Street 2:
Mailing Address - City:DESERT HOT SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92240-6977
Mailing Address - Country:US
Mailing Address - Phone:760-660-3961
Mailing Address - Fax:
Practice Address - Street 1:66659 EL DORADO PL
Practice Address - Street 2:
Practice Address - City:DESERT HOT SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92240-6977
Practice Address - Country:US
Practice Address - Phone:760-660-3961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1996343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)