Provider Demographics
NPI:1801913736
Name:DWIGHT JESSE CORNISH
Entity type:Organization
Organization Name:DWIGHT JESSE CORNISH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNISH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:760-568-9811
Mailing Address - Street 1:PO BOX 13888
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92255-3888
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:74824 LENNON PL
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-1901
Practice Address - Country:US
Practice Address - Phone:760-568-9811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-24
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7254225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT72542Medicare ID - Type UnspecifiedPT PROVIDER #