Healthcare Provider Details

I. General information

NPI: 1790652162
Provider Name (Legal Business Name): ITZIA ADILENE BASULTO MONTES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2025
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58457 TWENTYNINE PALMS HIGHWAY SUITE 102A
YUCCA VALLEY CA
92284
US

IV. Provider business mailing address

58457 TWENTYNINE PALMS HIGHWAY SUITE 102A
YUCCA VALLEY CA
92284
US

V. Phone/Fax

Practice location:
  • Phone: 760-228-9657
  • Fax: 442-205-0060
Mailing address:
  • Phone: 760-228-9657
  • Fax: 442-205-0060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-VMFYNA
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: