=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376970228
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COACHELLA VALLEY RETINA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2013
-----------------------------------------------------
Last Update Date | 11/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 72301 COUNTRY CLUB DR 108
-----------------------------------------------------
City | RANCHO MIRAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92270-8007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-895-1993
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 72301 COUNTRY CLUB DR 108
-----------------------------------------------------
City | RANCHO MIRAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92270-8007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-895-1993
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CAMILLE HARRISON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 760-895-1993
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------