=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194397414
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN TEETERS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2021
-----------------------------------------------------
Last Update Date | 07/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7293 DUMOSA AVE
-----------------------------------------------------
City | YUCCA VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92284-3700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-365-2233
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3128 SHAWNEE TRL
-----------------------------------------------------
City | LANDERS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92285-2054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-792-4121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164X00000X
-----------------------------------------------------
Taxonomy Name | Licensed Vocational Nurse
-----------------------------------------------------
License Number | 700945
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------