=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205181385
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNETTE CARPENTER B.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2012
-----------------------------------------------------
Last Update Date | 07/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 58923 BUSINESS CENTER DR STE. E
-----------------------------------------------------
City | YUCCA VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92284-7311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-228-7209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 60440 GRANADA DR
-----------------------------------------------------
City | JOSHUA TREE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92252-2761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-217-2775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------