Healthcare Provider Details

I. General information

NPI: 1447598222
Provider Name (Legal Business Name): REYMUNDO NOUR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2013
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81626 US HIGHWAY 111
INDIO CA
92201-5413
US

IV. Provider business mailing address

81626 US HIGHWAY 111
INDIO CA
92201-5413
US

V. Phone/Fax

Practice location:
  • Phone: 760-600-5825
  • Fax:
Mailing address:
  • Phone: 760-600-5825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberCLR00343403
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCLR00343403
License Number StateCA

VIII. Authorized Official

Name: REYMUNDO NOUR
Title or Position: MANAGER
Credential:
Phone: 760-600-5825