Healthcare Provider Details

I. General information

NPI: 1730630427
Provider Name (Legal Business Name): ANTELOPE VALLEY COMMUNITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45124 10TH ST W
LANCASTER CA
93534-2310
US

IV. Provider business mailing address

45104 10TH ST W
LANCASTER CA
93534-2310
US

V. Phone/Fax

Practice location:
  • Phone: 661-942-2391
  • Fax:
Mailing address:
  • Phone: 661-942-2391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number10016685
License Number StateCA

VIII. Authorized Official

Name: JAMES COOK
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 661-942-2391