Healthcare Provider Details

I. General information

NPI: 1346276813
Provider Name (Legal Business Name): KEITH R WRESCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 BOULDER AVE
HIGHLAND CA
92346-3348
US

IV. Provider business mailing address

PO BOX 2200
REDLANDS CA
92373-0722
US

V. Phone/Fax

Practice location:
  • Phone: 909-862-1191
  • Fax: 909-796-4158
Mailing address:
  • Phone: 909-793-3311
  • Fax: 909-796-4158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA90435
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: