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General NPI Number Information
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NPI Number | 1043241136
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Entity Type | Organization
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Legal Business Name | VALLEY INFECTIONS DISEASE MEDICAL GROUP INC A MEDICAL CORPORATION
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Dates
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Enumeration Date | 07/06/2006
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Last Update Date | 05/10/2017
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Provider Practice Location Address
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Address Line | 23928 LYONS AVE #208
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City | NEWHALL
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State | CA
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Zip | 91321-2409
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Country | US
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Telephone | 661-255-8544
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Fax | 661-255-9964
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Provider Business Mailing Address
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Address Line | 23928 LYONS AVE #208
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City | NEWHALL
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State | CA
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Zip | 91321-2409
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Country | US
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Telephone | 661-255-8544
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Fax | 661-255-9964
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ELLSWORTH PAXTON PRYOR, III
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Credential | M.D
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Telephone | 661-255-8544
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | G29880
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License Number State | CA
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