Healthcare Provider Details

I. General information

NPI: 1346563673
Provider Name (Legal Business Name): ANTELOPE VALLEY COMMUNITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2010
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 E PALMDALE BLVD
PALMDALE CA
93550-4037
US

IV. Provider business mailing address

45074 10TH STREET WEST SUITE 109
LANCASTER CA
93534-2382
US

V. Phone/Fax

Practice location:
  • Phone: 661-575-0009
  • Fax: 661-575-0015
Mailing address:
  • Phone: 661-575-0009
  • Fax: 661-575-0015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number550001129
License Number StateCA

VIII. Authorized Official

Name: MR. JAMES A. COOK
Title or Position: CEO
Credential:
Phone: 661-942-2391