Healthcare Provider Details

I. General information

NPI: 1891322269
Provider Name (Legal Business Name): PIERCE DERICO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 07/03/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 STURGIS ROAD
TWENTYNINE PALMS CA
92278-8275
US

IV. Provider business mailing address

1145 STURGIS ROAD
TWENTYNINE PALMS CA
92278
US

V. Phone/Fax

Practice location:
  • Phone: 760-830-2117
  • Fax:
Mailing address:
  • Phone: 760-830-2117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101273114
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: