Healthcare Provider Details

I. General information

NPI: 1790921641
Provider Name (Legal Business Name): CLINICA MEDICA DEL VALLE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2008
Last Update Date: 12/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52-565 HARRISON STREET SUITE 104
COACHELLA CA
92236-1534
US

IV. Provider business mailing address

52-565 HARRISON STREET SUITE 104
COACHELLA CA
92236-1534
US

V. Phone/Fax

Practice location:
  • Phone: 760-398-0606
  • Fax: 760-398-5507
Mailing address:
  • Phone: 760-398-0606
  • Fax: 760-398-5507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberA66595
License Number StateCA

VIII. Authorized Official

Name: DR. JUAN M ACOSTA
Title or Position: PRESIDENT
Credential: MD
Phone: 760-398-0606