Healthcare Provider Details

I. General information

NPI: 1306405949
Provider Name (Legal Business Name): MR. THEODORE R ROBINSON III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 SPRUCE ST STE A
RIVERSIDE CA
92507-2410
US

IV. Provider business mailing address

47915 OASIS ST
INDIO CA
92201-6950
US

V. Phone/Fax

Practice location:
  • Phone: 951-715-5050
  • Fax:
Mailing address:
  • Phone: 760-863-8638
  • Fax: 760-863-8812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: