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General NPI Number Information
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NPI Number | 1730265679
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Entity Type | Organization
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Legal Business Name | VICTOR VALLEY ANESTHESIA MEDICAL GROUP INC
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Dates
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Enumeration Date | 10/31/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 15248 11TH STREET
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City | VICTORVILLE
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State | CA
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Zip | 92395
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Country | US
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Telephone | 760-245-8691
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Fax | 760-245-8391
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Provider Business Mailing Address
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Address Line | 14762 KINAI RD
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City | APPLE VALLEY
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State | CA
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Zip | 92307-5120
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Country | US
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Telephone | 760-242-6561
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Fax | 760-242-1354
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Authorized Official
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Title or Position | MEDICAL DIRECTOR / PRESIDENT
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Name | DR. RAJENDER S THAKRAN
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Credential | M.D.
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Telephone | 760-242-6561
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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 | A55039
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License Number State | CA
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