Provider Demographics
NPI:1013151364
Name:CONCEPT MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:CONCEPT MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAJU
Authorized Official - Middle Name:
Authorized Official - Last Name:KHANCHUSTAMBHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:760-217-0126
Mailing Address - Street 1:36101 BOB HOPE DR
Mailing Address - Street 2:STE. E-5 #117
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-2006
Mailing Address - Country:US
Mailing Address - Phone:760-217-0126
Mailing Address - Fax:760-699-7750
Practice Address - Street 1:35400 BOB HOPE DR
Practice Address - Street 2:SUITE # 209
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-1772
Practice Address - Country:US
Practice Address - Phone:760-699-7117
Practice Address - Fax:760-699-7750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-29
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86478261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care