Provider Demographics
NPI:1932267556
Name:YUCCA VALLEY FAMILY MEDICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:YUCCA VALLEY FAMILY MEDICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELDENE
Authorized Official - Middle Name:ARNE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-367-6028
Mailing Address - Street 1:6380 SPLIT ROCK AVE
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277-2550
Mailing Address - Country:US
Mailing Address - Phone:760-367-6028
Mailing Address - Fax:760-367-2178
Practice Address - Street 1:6380 SPLIT ROCK AVE
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-2550
Practice Address - Country:US
Practice Address - Phone:760-367-6028
Practice Address - Fax:760-367-2178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38944261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA28767Medicare UPIN
CA00A389440Medicare ID - Type Unspecified