Basic Information
| Provider Information | |||||||||
| NPI: | 1962867754 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER HEALTH PARTNERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15248 11TH ST | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923953704 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 15248 11TH ST | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923953704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608436099 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2015 | ||||||||
| LastUpdateDate: | 12/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | CARDILLO | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3104882830 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | A82516 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.