=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588203988
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIGH DESERT EYE SURGERY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2020
-----------------------------------------------------
Last Update Date | 02/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16030 KAMANA ROAD
-----------------------------------------------------
City | APPLE VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92307-9230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-946-0618
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 N 13TH AVE
-----------------------------------------------------
City | UPLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91786-4904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 92-772-4209
-----------------------------------------------------
Fax | 909-206-1097
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF REVENUE OFFICER
-----------------------------------------------------
Name | CLIFTON CHAD BAZHAW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-270-6658
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS0132X
-----------------------------------------------------
Taxonomy Name | Ophthalmologic Surgery Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------