Healthcare Provider Details

I. General information

NPI: 1467506451
Provider Name (Legal Business Name): HALO MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 04/22/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74785 US HIGHWAY 111 SUITE 101
INDIAN WELLS CA
92210-7128
US

IV. Provider business mailing address

PO BOX 841163
LOS ANGELES CA
90084-1163
US

V. Phone/Fax

Practice location:
  • Phone: 760-776-8989
  • Fax: 760-501-0311
Mailing address:
  • Phone: 760-776-8989
  • Fax: 760-779-8073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberFNP25453
License Number StateCA

VIII. Authorized Official

Name: CORY HAMMOND
Title or Position: CFO
Credential:
Phone: 760-776-8989