Healthcare Provider Details

I. General information

NPI: 1720335359
Provider Name (Legal Business Name): HIGH DESERT SPECIALTY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2012
Last Update Date: 08/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17059 MAIN ST
HESPERIA CA
92345-6067
US

IV. Provider business mailing address

17095 MAIN ST
HESPERIA CA
92345-6004
US

V. Phone/Fax

Practice location:
  • Phone: 760-241-6666
  • Fax: 760-241-7575
Mailing address:
  • Phone: 760-956-4170
  • Fax: 760-956-4172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: ZIAD R EL-HAJJAOUI
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 760-241-6666