Healthcare Provider Details

I. General information

NPI: 1538202023
Provider Name (Legal Business Name): KENNETH RAY BOWLING JR. IMF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68615 PEREZ RD
CATHEDRAL CITY CA
92234-7200
US

IV. Provider business mailing address

68615 PEREZ ROAD
CATHEDRAL CITY CA
92234-7200
US

V. Phone/Fax

Practice location:
  • Phone: 760-770-2286
  • Fax:
Mailing address:
  • Phone: 760-770-2286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMF 76911
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: