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General NPI Number Information
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NPI Number | 1043315120
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Entity Type | Organization
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Legal Business Name | ANTELOPE VALLEY IMPOTENCE & INCONTINENCE MEDICAL CENTER, INC
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Dates
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Enumeration Date | 09/14/2006
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Last Update Date | 01/31/2025
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Provider Practice Location Address
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Address Line | 38921 TRADE CENTER DR
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City | PALMDALE
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State | CA
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Zip | 93551-3652
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Country | US
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Telephone | 661-945-0601
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Fax | 833-974-2391
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Provider Business Mailing Address
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Address Line | 38921 TRADE CENTER DR
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City | PALMDALE
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State | CA
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Zip | 93551-3652
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Country | US
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Telephone | 661-945-0601
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Fax | 833-974-2391
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Authorized Official
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Title or Position | CEO/UROLOGIST
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Name | MR. EUGENE CLEMENT RAJARATNAIN
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Credential | MD FACS
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Telephone | 661-945-0601
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | C042345
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License Number State | CA
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