Healthcare Provider Details

I. General information

NPI: 1588972806
Provider Name (Legal Business Name): ST MARY SPECIALTY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2010
Last Update Date: 05/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19333 BEAR VALLEY RD STE 106
APPLE VALLEY CA
92308-5149
US

IV. Provider business mailing address

DEPT LA 21190
PASADENA CA
91185-1190
US

V. Phone/Fax

Practice location:
  • Phone: 760-240-5505
  • Fax: 760-240-5525
Mailing address:
  • Phone: 714-449-4800
  • Fax: 714-449-4956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MOSES T MUKAI JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 714-449-4800