Provider Demographics
NPI:1548288574
Name:INDIAN WELLS MEDICAL CENTER
Entity type:Organization
Organization Name:INDIAN WELLS MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:760-568-4544
Mailing Address - Street 1:74976 HIGHWAY 111
Mailing Address - Street 2:
Mailing Address - City:INDIAN WELLS
Mailing Address - State:CA
Mailing Address - Zip Code:92210
Mailing Address - Country:US
Mailing Address - Phone:760-568-4544
Mailing Address - Fax:760-568-4555
Practice Address - Street 1:74976 US HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:INDIAN WELLS
Practice Address - State:CA
Practice Address - Zip Code:92210-7117
Practice Address - Country:US
Practice Address - Phone:760-568-4544
Practice Address - Fax:760-568-4555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2008-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26074111N00000X
CAC29564207R00000X
CAPT19355225100000X
CAA28654208D00000X
CAA83821207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ13979ZOtherBLUE SHIELD PROVIDER #
CAZZZ13978ZOtherBLUE SHIELD TRI-CARE WEST
CA5989270001Medicare NSC
CAZZZ29816ZMedicare PIN