Provider Demographics
NPI:1356811061
Name:MIRAGE MEDICAL GROUP CENTER
Entity type:Organization
Organization Name:MIRAGE MEDICAL GROUP CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ZORAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBAKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-346-4003
Mailing Address - Street 1:44650 VILLAGE CT STE 100
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-3812
Mailing Address - Country:US
Mailing Address - Phone:760-346-4003
Mailing Address - Fax:760-346-4443
Practice Address - Street 1:44650 VILLAGE CT STE 100
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-3812
Practice Address - Country:US
Practice Address - Phone:760-346-4003
Practice Address - Fax:760-346-4443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty