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General NPI Number Information
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NPI Number | 1871928945
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Entity Type | Organization
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Legal Business Name | COACHELLA VALLEY RETINA
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Dates
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Enumeration Date | 09/09/2013
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Last Update Date | 10/18/2013
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Provider Practice Location Address
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Address Line | 72301 COUNTRY CLUB DR STE 108
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City | RANCHO MIRAGE
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State | CA
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Zip | 92270-8007
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Country | US
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Telephone | 760-895-1993
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Fax | 760-862-1992
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Provider Business Mailing Address
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Address Line | 72-301 COUNTRY CLUB DRIVE , SUITE 108
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City | RANCHO MIRAGE
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State | CA
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Zip | 92270
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Country | US
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Telephone | 760-895-1993
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Fax | 760-862-1992
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Authorized Official
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Title or Position | PRESIDENT
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Name | CAMILLE HARRISON
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Credential | MD
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Telephone | 760-464-8244
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | A64900
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License Number State | CA
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