Healthcare Provider Details

I. General information

NPI: 1457490088
Provider Name (Legal Business Name): DENNIS MARK MATLOCK RS1503
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DENNIS MARK MATLOCK RS1503

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
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 2023
YUCCA VALLEY CA
92286-2023
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: