Basic Information
| Provider Information | |||||||||
| NPI: | 1710199674 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ANTELOPE VALLEY COMMUNITY CLINIC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ANTELOPE VALLEY COMMUNITY CLINIC - MOBILE HEALTH CLINIC I | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 45074 10TH ST W | ||||||||
| Address2: | SUITE 109 | ||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935342371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619422391 | ||||||||
| FaxNumber: | 6619026839 | ||||||||
| Practice Location | |||||||||
| Address1: | 45104 10TH ST W | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935342310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619422391 | ||||||||
| FaxNumber: | 6619026839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 09/12/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COOK | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6619422391 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ANTELOPE VALLEY COMMUNITY CLINIC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 060000428 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | CMM70633H | 01 | CA | MEDI-CAL | OTHER | CT556A | 01 | CA | MEDICARE PTAN | OTHER |