Healthcare Provider Details

I. General information

NPI: 1366967689
Provider Name (Legal Business Name): SUMMIT LEADERSHIP ACADEMY - HIGH DESERT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2017
Last Update Date: 07/21/2022
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12850 MUSCATEL ST
HESPERIA CA
92344-5566
US

IV. Provider business mailing address

12850 MUSCATEL ST
HESPERIA CA
92344-5566
US

V. Phone/Fax

Practice location:
  • Phone: 760-949-0202
  • Fax: 760-949-9257
Mailing address:
  • Phone: 760-949-0202
  • Fax: 760-949-9257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number36-75044
License Number StateCA

VIII. Authorized Official

Name: MISS DESIREE GARDNER
Title or Position: DIRECTOR, BUSINESS SERVICES
Credential:
Phone: 760-949-9202