Provider Demographics
NPI:1104105071
Name:JACOME MEDICAL GROUP
Entity type:Organization
Organization Name:JACOME MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ENRIQUE
Authorized Official - Middle Name:G
Authorized Official - Last Name:JACOME
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-773-2616
Mailing Address - Street 1:72780 COUNTRY CLUB DR
Mailing Address - Street 2:SUITE D403
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4126
Mailing Address - Country:US
Mailing Address - Phone:760-773-2616
Mailing Address - Fax:760-773-5797
Practice Address - Street 1:72780 COUNTRY CLUB DR
Practice Address - Street 2:SUITE D403
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4126
Practice Address - Country:US
Practice Address - Phone:760-773-2616
Practice Address - Fax:760-773-5797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-10
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44682174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty