Healthcare Provider Details

I. General information

NPI: 1639405004
Provider Name (Legal Business Name): HIGH DESERT FAMILY MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7350 CHURCH ST
YUCCA VALLEY CA
92284-3246
US

IV. Provider business mailing address

PO BOX 1220
JOSHUA TREE CA
92252-0810
US

V. Phone/Fax

Practice location:
  • Phone: 760-369-3069
  • Fax: 760-369-3072
Mailing address:
  • Phone: 760-369-3069
  • Fax: 760-369-3072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: ANDRE MARTIN KASKO
Title or Position: PRESIDENT/CEO
Credential: DO
Phone: 760-369-3069