Healthcare Provider Details

I. General information

NPI: 1386467561
Provider Name (Legal Business Name): SAMUEL HOWARD BABKOW FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1293 6TH ST
COACHELLA CA
92236-1707
US

IV. Provider business mailing address

41740 TRINITY CIR
BERMUDA DUNES CA
92203-1274
US

V. Phone/Fax

Practice location:
  • Phone: 760-775-4181
  • Fax:
Mailing address:
  • Phone: 760-774-3571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95032701
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: