Healthcare Provider Details

I. General information

NPI: 1760682140
Provider Name (Legal Business Name): ANTELOPE VALLEY LUNG INSTITUTE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 03/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 W AVENUE J SUITE 101
LANCASTER CA
93534-2942
US

IV. Provider business mailing address

1331 W AVENUE J SUITE 101
LANCASTER CA
93534-2942
US

V. Phone/Fax

Practice location:
  • Phone: 661-945-8717
  • Fax: 661-945-4867
Mailing address:
  • Phone: 661-945-8717
  • Fax: 661-945-4867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. PRADEEP BALKRISHNA DAMLE
Title or Position: PARTNER
Credential: MD
Phone: 661-945-8717