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General NPI Number Information
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NPI Number | 1629392675
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Entity Type | Organization
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Legal Business Name | MORONGO BASIN OB/GYN MEDICAL GROUP INC
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Dates
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Enumeration Date | 03/19/2010
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Last Update Date | 03/19/2010
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Provider Practice Location Address
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Address Line | 63532 29 PALMS HWY STE#D
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City | JOSHUA TREE
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State | CA
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Zip | 92252-0810
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Country | US
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Telephone | 760-366-1800
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Fax | 760-366-2155
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Provider Business Mailing Address
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Address Line | PO BOX 1220
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City | JOSHUA TREE
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State | CA
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Zip | 92252-0810
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Country | US
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Telephone | 760-366-1800
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Fax | 760-366-2155
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Authorized Official
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Title or Position | CEO
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Name | DR. ANDRE MARTIN KASKO
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Credential | D.O.
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Telephone | 760-366-1800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207VG0400X
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Taxonomy Name | Gynecology Physician
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License Number | 20A6300
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207VX0000X
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Taxonomy Name | Obstetrics Physician
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License Number | 20A6300
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License Number State | CA
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