Healthcare Provider Details

I. General information

NPI: 1396807202
Provider Name (Legal Business Name): HI-DESERT P.E.T. & NUCLEAR IMAGING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17260 BEAR VALLEY RD SUITE 114
VICTORVILLE CA
92395-7777
US

IV. Provider business mailing address

17260 BEAR VALLEY RD SUITE 114
VICTORVILLE CA
92395-7777
US

V. Phone/Fax

Practice location:
  • Phone: 760-955-9119
  • Fax: 760-955-9118
Mailing address:
  • Phone: 760-955-9119
  • Fax: 760-955-9118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberBSL06-03366
License Number StateCA

VIII. Authorized Official

Name: DR. KHALID M SHEIKH
Title or Position: PRESIDENT
Credential: PH.D
Phone: 760-955-9119