Healthcare Provider Details

I. General information

NPI: 1265288559
Provider Name (Legal Business Name): DOLLY MARIE BAXTER II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2024
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 RUSTIN AVE
RIVERSIDE CA
92507-2498
US

IV. Provider business mailing address

700 PORTERFIELD DR
SAN JACINTO CA
92582-2531
US

V. Phone/Fax

Practice location:
  • Phone: 951-715-5040
  • Fax:
Mailing address:
  • Phone: 951-421-2629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberAO62460423
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: