Provider Demographics
NPI:1619251576
Name:DESERT PROSTHETICS & ORTHOTICS GROUP
Entity Type:Organization
Organization Name:DESERT PROSTHETICS & ORTHOTICS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NEAL
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:760-770-4620
Mailing Address - Street 1:68860 PEREZ ROAD STE G
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234
Mailing Address - Country:US
Mailing Address - Phone:760-770-4620
Mailing Address - Fax:760-770-4622
Practice Address - Street 1:57402 TWENTYNINE PALMS HWY
Practice Address - Street 2:8
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284
Practice Address - Country:US
Practice Address - Phone:760-770-4620
Practice Address - Fax:760-770-4622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC000090Medicaid
CAGXC000090Medicaid