Healthcare Provider Details

I. General information

NPI: 1669978664
Provider Name (Legal Business Name): ALEXANDRA BLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2018
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41990 COOK ST BLDG F
PALM DESERT CA
92211-6100
US

IV. Provider business mailing address

41990 COOK ST
PALM DESERT CA
92211-6100
US

V. Phone/Fax

Practice location:
  • Phone: 760-565-5545
  • Fax:
Mailing address:
  • Phone: 760-565-5545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5982
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: