Basic Information
| Provider Information | |||||||||
| NPI: | 1417224007 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VICTOR VALLEY EMERGENCY MEDICAL ASSOCIATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 N SEPULVEDA BLVD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902666861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103792134 | ||||||||
| FaxNumber: | 3103794856 | ||||||||
| Practice Location | |||||||||
| Address1: | 15248 ELEVENTH ST | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923953704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608436099 | ||||||||
| FaxNumber: | 7608436010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2011 | ||||||||
| LastUpdateDate: | 01/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | EDWARDS | ||||||||
| AuthorizedOfficialFirstName: | IRV | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3103792134 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.