Healthcare Provider Details

I. General information

NPI: 1942718317
Provider Name (Legal Business Name): ANTONIA PRIDEMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83912 AVENUE 45 STE 9
INDIO CA
92201-3338
US

IV. Provider business mailing address

12283 SUMAC DR
DESERT HOT SPRINGS CA
92240-4013
US

V. Phone/Fax

Practice location:
  • Phone: 760-347-0754
  • Fax:
Mailing address:
  • Phone: 760-831-3084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: