MEDICARE: ANTELOPE VALLEY NEPHROLOGY MEDICAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	954053663	OTHER	CA	TAX ID
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336172949
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANTELOPE VALLEY NEPHROLOGY MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	PO BOX 2768
Second Line	:
City	:	LANCASTER
State	:	CA
Zip	:	93539-2768
Country	:	US
Telephone Number	:	661-948-8309
Fax Number	:	661-948-8907

Provider Business Practice Location Address
First Line	:	1759 W AVENUE J # 101
Second Line	:
City	:	LANCASTER
State	:	CA
Zip	:	93534-2703
Country	:	US
Telephone Number	:	661-948-1388
Fax Number	:	661-948-1223

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DR. SUNG C YANG
Credential	:	M.D.
Telephone Number	:	661-948-1388

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	02/23/2016

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