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General NPI Number Information
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NPI Number | 1013151364
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Entity Type | Organization
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Legal Business Name | CONCEPT MEDICAL ASSOCIATES
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Dates
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Enumeration Date | 04/29/2009
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Last Update Date | 05/11/2009
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Provider Practice Location Address
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Address Line | 35400 BOB HOPE DR SUITE # 209
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City | RANCHO MIRAGE
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State | CA
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Zip | 92270-1772
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Country | US
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Telephone | 760-699-7117
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Fax | 760-699-7750
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Provider Business Mailing Address
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Address Line | 36101 BOB HOPE DR STE. E-5 #117
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City | RANCHO MIRAGE
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State | CA
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Zip | 92270-2006
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Country | US
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Telephone | 760-217-0126
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Fax | 760-699-7750
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. RAJU KHANCHUSTAMBHAM
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Credential | MS
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Telephone | 760-217-0126
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | A86478
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License Number State | CA
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