Healthcare Provider Details

I. General information

NPI: 1619307451
Provider Name (Legal Business Name): RANCHO DEL CIELO MALIBU
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2013
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5591 DE BUTTS TER
MALIBU CA
90265-1709
US

IV. Provider business mailing address

PO BOX 6704
MALIBU CA
90264-6704
US

V. Phone/Fax

Practice location:
  • Phone: 310-589-9398
  • Fax:
Mailing address:
  • Phone: 310-589-9398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. SPARKY GREENE
Title or Position: CEO
Credential:
Phone: 310-344-5558