Healthcare Provider Details

I. General information

NPI: 1962784595
Provider Name (Legal Business Name): JEFFERY MICHAEL DEATHERAGE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36101 BOB HOPE DR STE A
RANCHO MIRAGE CA
92270-2001
US

IV. Provider business mailing address

36101 BOB HOPE DR STE A
RANCHO MIRAGE CA
92270-2001
US

V. Phone/Fax

Practice location:
  • Phone: 760-321-1315
  • Fax: 760-321-1094
Mailing address:
  • Phone: 760-321-1315
  • Fax: 760-321-1094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number16116
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: