Healthcare Provider Details

I. General information

NPI: 1184343063
Provider Name (Legal Business Name): MARK JOSEPH MCGOWAN SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2022
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83912 AVENUE 45 STE 9
INDIO CA
92201-3338
US

IV. Provider business mailing address

PO BOX 3051
INDIO CA
92202-3051
US

V. Phone/Fax

Practice location:
  • Phone: 760-347-0754
  • Fax:
Mailing address:
  • Phone: 760-699-3968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCI34461221
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: