Provider Demographics
NPI:1043315120
Name:ANTELOPE VALLEY IMPOTENCE & INCONTINENCE MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:ANTELOPE VALLEY IMPOTENCE & INCONTINENCE MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/UROLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:CLEMENT
Authorized Official - Last Name:RAJARATNAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD FACS
Authorized Official - Phone:661-945-0601
Mailing Address - Street 1:44241 NORTH 15TH STREET WEST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534
Mailing Address - Country:US
Mailing Address - Phone:661-945-0601
Mailing Address - Fax:661-949-5965
Practice Address - Street 1:44241 NORTH 15TH STREET WEST
Practice Address - Street 2:SUITE 101
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534
Practice Address - Country:US
Practice Address - Phone:661-945-0601
Practice Address - Fax:661-949-5965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC042345208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOC423450Medicaid
CAOOC423450Medicaid
CAC42345Medicare ID - Type Unspecified