Healthcare Provider Details

I. General information

NPI: 1891836136
Provider Name (Legal Business Name): CARTER EVANS CHILDS RAS-C0509020847
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 09/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83912 AVENUE 45 SUITE #9
INDIO CA
92201-3338
US

IV. Provider business mailing address

PO BOX 355
LA QUINTA CA
92247-0355
US

V. Phone/Fax

Practice location:
  • Phone: 760-347-0754
  • Fax: 760-347-8507
Mailing address:
  • Phone: 760-347-0754
  • Fax: 760-347-8507

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: