Healthcare Provider Details

I. General information

NPI: 1659395507
Provider Name (Legal Business Name): DEBORAH PALMER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 11/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 HUNTINGTON DR STE 5
SAN MARINO CA
91108-2044
US

IV. Provider business mailing address

2060 HUNTINGTON DR STE 5
SAN MARINO CA
91108-2044
US

V. Phone/Fax

Practice location:
  • Phone: 626-570-1993
  • Fax: 626-570-4993
Mailing address:
  • Phone: 626-570-1993
  • Fax: 626-570-4993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberBL 001681
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: