Healthcare Provider Details

I. General information

NPI: 1104466929
Provider Name (Legal Business Name): DOLORES JAZMIN RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47915 OASIS ST
INDIO CA
92201-6950
US

IV. Provider business mailing address

88-455 AVE. 57TH SPACE 4
THERMAL CA
92274
US

V. Phone/Fax

Practice location:
  • Phone: 760-863-8600
  • Fax:
Mailing address:
  • Phone: 442-200-8922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: