Healthcare Provider Details

I. General information

NPI: 1548288574
Provider Name (Legal Business Name): INDIAN WELLS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 03/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74976 US HIGHWAY 111
INDIAN WELLS CA
92210-7117
US

IV. Provider business mailing address

74976 HIGHWAY 111
INDIAN WELLS CA
92210
US

V. Phone/Fax

Practice location:
  • Phone: 760-568-4544
  • Fax: 760-568-4555
Mailing address:
  • Phone: 760-568-4544
  • Fax: 760-568-4555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC26074
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC29564
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT19355
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA28654
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA83821
License Number StateCA

VIII. Authorized Official

Name: DR. CORVIN KELLY
Title or Position: DIRECTOR/OFFICER
Credential: D.C.
Phone: 760-568-4544