Provider Demographics
NPI:1518293356
Name:CENTRAL DESERT INDUSTRIAL MEDICAL GROUP A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CENTRAL DESERT INDUSTRIAL MEDICAL GROUP A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE OPERATIONS DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GROVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-242-7003
Mailing Address - Street 1:18031 US HIGHWAY 18
Mailing Address - Street 2:SUITE F
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2152
Mailing Address - Country:US
Mailing Address - Phone:760-242-7003
Mailing Address - Fax:730-242-7703
Practice Address - Street 1:18031 US HIGHWAY 18
Practice Address - Street 2:SUITE F
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2152
Practice Address - Country:US
Practice Address - Phone:760-242-7003
Practice Address - Fax:730-242-7703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-29
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5179261QX0100X
CA12656PA261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine