Healthcare Provider Details

I. General information

NPI: 1306727599
Provider Name (Legal Business Name): ANTELOPE VALLEY PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2025
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 661-414-7016
  • Fax:
Mailing address:
  • Phone: 661-414-7016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. VINCENT M ESTACIO
Title or Position: PARTNER
Credential: RN
Phone: 661-673-3204