Provider Demographics
NPI:1356452437
Name:MATTIE EVANS ALDERMAN FOUNDATION, INC.
Entity Type:Organization
Organization Name:MATTIE EVANS ALDERMAN FOUNDATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:HARMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-345-2696
Mailing Address - Street 1:41800 WASHINGTON ST
Mailing Address - Street 2:SUITE #110
Mailing Address - City:BERMUDA DUNES
Mailing Address - State:CA
Mailing Address - Zip Code:92203-8150
Mailing Address - Country:US
Mailing Address - Phone:760-345-2696
Mailing Address - Fax:760-345-4961
Practice Address - Street 1:41800 WASHINGTON ST
Practice Address - Street 2:SUITE #110
Practice Address - City:BERMUDA DUNES
Practice Address - State:CA
Practice Address - Zip Code:92203-8150
Practice Address - Country:US
Practice Address - Phone:760-345-2696
Practice Address - Fax:760-345-4961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA27983261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ22276ZMedicare PIN