=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205399334
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DESERT WELLNESS PSYCHIATRY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2019
-----------------------------------------------------
Last Update Date | 04/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35800 BOB HOPE DR STE 210
-----------------------------------------------------
City | RANCHO MIRAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92270-1739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-537-4223
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35800 BOB HOPE DR STE 210
-----------------------------------------------------
City | RANCHO MIRAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92270-1739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO, PRESIDENT
-----------------------------------------------------
Name | DR. JUAN LUA GONZALEZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 760-537-4223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------