Basic Information
| Provider Information | |||||||||
| NPI: | 1851396576 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DESERT VALLEY HOSPITAL, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DESERT VALLEY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 16850 BEAR VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923955794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602418000 | ||||||||
| FaxNumber: | 7609512034 | ||||||||
| Practice Location | |||||||||
| Address1: | 16850 BEAR VALLEY RD | ||||||||
| Address2: | ATTENTION HOSPITAL BUSINESS OFFICE | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923955794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602418000 | ||||||||
| FaxNumber: | 7609512034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DOAN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING ASSOCIATE GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 3102594706 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRIME HEALTHCARE SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 240000562 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSP30709F | 05 | CA | MEDICAID | HSP40709F | 05 | CA | MEDICAID |