MEDICARE: MRS. IDA DAGHER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374700000X	Technician	L9605	CA

General Provider Information

NPI Number	:	1255894408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. IDA DAGHER

Provider Business Mailing Address
First Line	:	1814 JEANNA PL
Second Line	:
City	:	UPLAND
State	:	CA
Zip	:	91784-9262
Country	:	US
Telephone Number	:	626-833-6987
Fax Number	:

Provider Business Practice Location Address
First Line	:	35325 DATE PALM DR STE 107
Second Line	:
City	:	CATHEDRAL CITY
State	:	CA
Zip	:	92234-7032
Country	:	US
Telephone Number	:	760-202-4308
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2019
Last Update Date	:	04/12/2019

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