Healthcare Provider Details

I. General information

NPI: 1134456627
Provider Name (Legal Business Name): FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY OF THE HIGH DESERT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2009
Last Update Date: 03/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19333 BEAR VALLEY RD SUITE 106
APPLE VALLEY CA
92308-5148
US

IV. Provider business mailing address

19333 BEAR VALLEY ROAD SUITE 106
APPLE VALLEY CA
92308-0000
US

V. Phone/Fax

Practice location:
  • Phone: 760-946-5177
  • Fax: 760-946-5133
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number20A5527
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number20A5527
License Number StateCA

VIII. Authorized Official

Name: DR. MOSES T MUKAI
Title or Position: PRESIDENT
Credential: D.O.
Phone: 760-946-5177