Healthcare Provider Details

I. General information

NPI: 1740505742
Provider Name (Legal Business Name): ALLIANCE DESERT PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2010
Last Update Date: 04/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17259 JASMINE ST SUITE B
VICTORVILLE CA
92395-7787
US

IV. Provider business mailing address

17259 JASMINE ST SUITE B
VICTORVILLE CA
92395-7787
US

V. Phone/Fax

Practice location:
  • Phone: 760-241-4929
  • Fax:
Mailing address:
  • Phone: 760-241-4929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA74104
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA54985
License Number StateCA

VIII. Authorized Official

Name: DR. DENNIS P. FLYNN
Title or Position: VICE PRESIDENT OF MEDICAL AFFAIRS
Credential: M.D.
Phone: 909-335-4101