Provider Demographics
NPI:1063465474
Name:DESERT VALLEY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:DESERT VALLEY MEDICAL GROUP, INC.
Other - Org Name:PRIMECARE MEDICAL GROUP OF DESERT VALLEY, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAVITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BHATIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-241-8000
Mailing Address - Street 1:16850 BEAR VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5794
Mailing Address - Country:US
Mailing Address - Phone:760-241-8000
Mailing Address - Fax:
Practice Address - Street 1:16716 BEAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5797
Practice Address - Country:US
Practice Address - Phone:760-241-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACC8406OtherRAILROAD MEDICARE
CAZZZ23742ZMedicare ID - Type Unspecified