Provider Demographics
NPI:1508239237
Name:PHILLIPS, DAMIEN ALEXANDER
Entity Type:Individual
Prefix:
First Name:DAMIEN
Middle Name:ALEXANDER
Last Name:PHILLIPS
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 1:2765 BACH AVE
Mailing Address - Street 2:
Mailing Address - City:THERMAL
Mailing Address - State:CA
Mailing Address - Zip Code:92274-6565
Mailing Address - Country:US
Mailing Address - Phone:714-728-7694
Mailing Address - Fax:
Practice Address - Street 1:47915 OASIS ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-6950
Practice Address - Country:US
Practice Address - Phone:760-863-8638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00841747376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00841747OtherNURSE ASSISTANT CERTIFICATION