Healthcare Provider Details

I. General information

NPI: 1942163761
Provider Name (Legal Business Name): TIFFANY MARILYN BOUGOUMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41550 ECLECTIC ST
PALM DESERT CA
92260-1967
US

IV. Provider business mailing address

41550 ECLECTIC ST
PALM DESERT CA
92260-1967
US

V. Phone/Fax

Practice location:
  • Phone: 877-205-6269
  • Fax:
Mailing address:
  • Phone: 877-205-6269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: