Healthcare Provider Details

I. General information

NPI: 1760579312
Provider Name (Legal Business Name): DERALD R NORDECK RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 WEST LUGONIA AVENUE SUITE 120
REDLANDS CA
92374
US

IV. Provider business mailing address

PO BOX 8520
REDLANDS CA
92374
US

V. Phone/Fax

Practice location:
  • Phone: 909-557-1600
  • Fax: 909-557-1740
Mailing address:
  • Phone: 909-557-1600
  • Fax: 909-557-1740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0800X
TaxonomyOrthopedic Registered Nurse
License Number350141
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: