Healthcare Provider Details

I. General information

NPI: 1114799178
Provider Name (Legal Business Name): AV BRIDGES MENTAL HEALTH CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 W. AVE J UNIT 101A
LANCASTER CA
93534
US

IV. Provider business mailing address

1331 W. AVE J UNIT 101A
LANCASTER CA
93534
US

V. Phone/Fax

Practice location:
  • Phone: 661-310-3110
  • Fax: 661-310-3112
Mailing address:
  • Phone: 661-310-3110
  • Fax: 661-310-3112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: VINCENT ESTACIO
Title or Position: RN/CEO
Credential:
Phone: 661-310-3110