Healthcare Provider Details

I. General information

NPI: 1114912979
Provider Name (Legal Business Name): ANTELOPE VALLEY NEUROSCIENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 10/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42135 10TH ST W SUITE 301
LANCASTER CA
93534-7095
US

IV. Provider business mailing address

42135 10TH ST W SUITE 301
LANCASTER CA
93534-7095
US

V. Phone/Fax

Practice location:
  • Phone: 661-945-6931
  • Fax: 661-945-4592
Mailing address:
  • Phone: 661-945-6931
  • Fax: 661-945-4592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP20677
License Number StateCA

VIII. Authorized Official

Name: ABDALLAH S FARRUKH
Title or Position: PARTNER
Credential: MD
Phone: 661-945-6931