Healthcare Provider Details

I. General information

NPI: 1295670792
Provider Name (Legal Business Name): MICHAEL BUTLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7346 DUMOSA AVE APT B
YUCCA VALLEY CA
92284-7907
US

IV. Provider business mailing address

7346 DUMOSA AVE APT B
YUCCA VALLEY CA
92284-7907
US

V. Phone/Fax

Practice location:
  • Phone: 442-451-6190
  • Fax:
Mailing address:
  • Phone: 442-451-6190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number1295670792
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: