Provider Demographics
NPI:1255754693
Name:UCR PALM SPRINGS - EL MIRADOR PRACTICE
Entity type:Organization
Organization Name:UCR PALM SPRINGS - EL MIRADOR PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. ASSOC. DEAN, CLINICAL AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HEYDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-456-2986
Mailing Address - Street 1:PO BOX 54779
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90054-0779
Mailing Address - Country:US
Mailing Address - Phone:866-819-6298
Mailing Address - Fax:
Practice Address - Street 1:1180 N INDIAN CANYON DR
Practice Address - Street 2:SUITE E425
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4800
Practice Address - Country:US
Practice Address - Phone:760-537-1632
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF CALIFORNIA REGENTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty