Healthcare Provider Details

I. General information

NPI: 1831489152
Provider Name (Legal Business Name): ANTELOPE VALLEY LUNG INSTITUTE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2011
Last Update Date: 04/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 HERITAGE WAY, BLDG A
RIDGECREST CA
93555
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 760-446-4571
  • Fax: 661-945-4867
Mailing address:
  • Phone: 661-945-8717
  • Fax: 661-945-4867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA87434
License Number StateCA

VIII. Authorized Official

Name: DR. SYED SAJEEL AHMED
Title or Position: PARTNER
Credential: M.D.
Phone: 760-446-4571