Provider Demographics
NPI:1962700260
Name:RANCHO MIRAGE FERTILITY MEDICAL CLINIC
Entity type:Organization
Organization Name:RANCHO MIRAGE FERTILITY MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:AMADOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-346-4334
Mailing Address - Street 1:1199 N. INDIAN CANYON DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262
Mailing Address - Country:US
Mailing Address - Phone:760-346-4334
Mailing Address - Fax:760-346-3663
Practice Address - Street 1:1199 N. INDIAN CANYON DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-5516
Practice Address - Country:US
Practice Address - Phone:760-346-4334
Practice Address - Fax:760-346-3663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-10
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52107174400000X
CAH83663174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH83663Medicare UPIN
CAG99679Medicare UPIN