Healthcare Provider Details

I. General information

NPI: 1609329002
Provider Name (Legal Business Name): JEFFREY IDICA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 E PALM CANYON DR STE 310
PALM SPRINGS CA
92264
US

IV. Provider business mailing address

1775 E PALM CANYON DR STE 310
PALM SPRINGS CA
92264-1646
US

V. Phone/Fax

Practice location:
  • Phone: 424-335-9110
  • Fax:
Mailing address:
  • Phone: 424-335-9110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberND753
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: