Provider Demographics
NPI:1154783140
Name:ANTELOPE VALLEY HOSPITAL OB CLINIC PALMDALE
Entity type:Organization
Organization Name:ANTELOPE VALLEY HOSPITAL OB CLINIC PALMDALE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-949-5512
Mailing Address - Street 1:1600 W AVENUE J
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2814
Mailing Address - Country:US
Mailing Address - Phone:661-726-6325
Mailing Address - Fax:
Practice Address - Street 1:38350 40TH ST E
Practice Address - Street 2:SUITE 200
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93552-3075
Practice Address - Country:US
Practice Address - Phone:661-726-6325
Practice Address - Fax:661-726-6333
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANTELOPE VALLEY HEALTHCARE DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-28
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1366419517Medicaid
CA1366419517Medicaid