=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922028539
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIGH DESERT NEURO-DIAGNOSTIC MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2006
-----------------------------------------------------
Last Update Date | 06/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18523 CORWIN RD SUITE A
-----------------------------------------------------
City | APPLE VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92307-2338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-946-3876
-----------------------------------------------------
Fax | 760-242-1936
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18523 CORWIN ROAD SUITE A
-----------------------------------------------------
City | APPLE VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92307-2338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-946-3876
-----------------------------------------------------
Fax | 760-242-1936
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MANMOHAN NAYYAR
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 760-946-3876
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------