Healthcare Provider Details

I. General information

NPI: 1134519960
Provider Name (Legal Business Name): DEBRA HIDALGO I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2015
Last Update Date: 02/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32770 OLD WOMAN SPRINGS RD.
LUCERNE VALLEY CA
92356
US

IV. Provider business mailing address

PO BOX 1927
BIG BEAR LAKE CA
92315-1927
US

V. Phone/Fax

Practice location:
  • Phone: 760-248-6612
  • Fax: 760-248-3389
Mailing address:
  • Phone: 760-248-6612
  • Fax: 760-248-3389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: