Healthcare Provider Details

I. General information

NPI: 1356945562
Provider Name (Legal Business Name): PEACOCK DESERT ROSE SERVICES LIMITED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2020
Last Update Date: 11/29/2020
Certification Date: 11/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

967 KENDALL DR # A329
SAN BERNARDINO CA
92407-4306
US

IV. Provider business mailing address

967 KENDALL DR # A329
SAN BERNARDINO CA
92407-4306
US

V. Phone/Fax

Practice location:
  • Phone: 909-689-6095
  • Fax:
Mailing address:
  • Phone: 909-689-6095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: KAI HARPER
Title or Position: PRESIDENT
Credential:
Phone: 909-689-6095