Healthcare Provider Details

I. General information

NPI: 1417224007
Provider Name (Legal Business Name): VICTOR VALLEY EMERGENCY MEDICAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2011
Last Update Date: 01/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15248 ELEVENTH ST
VICTORVILLE CA
92395-3704
US

IV. Provider business mailing address

111 N SEPULVEDA BLVD SUITE 210
MANHATTAN BEACH CA
90266-6861
US

V. Phone/Fax

Practice location:
  • Phone: 760-843-6099
  • Fax: 760-843-6010
Mailing address:
  • Phone: 310-379-2134
  • Fax: 310-379-4856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: IRV E EDWARDS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-379-2134