Healthcare Provider Details

I. General information

NPI: 1295819639
Provider Name (Legal Business Name): ALPINE CREEK AND PINE VALLEY FAMILY MEDICINE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1347 TAVERN RD STE 9
ALPINE CA
91901-3897
US

IV. Provider business mailing address

1347 TAVERN RD STE 9
ALPINE CA
91901-3897
US

V. Phone/Fax

Practice location:
  • Phone: 619-445-0205
  • Fax: 619-659-0205
Mailing address:
  • Phone: 619-445-0205
  • Fax: 619-659-0205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number20A4384
License Number StateCA

VIII. Authorized Official

Name: JAMES M RICKETTS
Title or Position: CEO
Credential: D.O.
Phone: 619-445-0204