Provider Demographics
NPI:1083759195
Name:VICTOR VALLEY NEUROLOGY, INC
Entity Type:Organization
Organization Name:VICTOR VALLEY NEUROLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NOEL
Authorized Official - Middle Name:CUEVAS
Authorized Official - Last Name:BERNALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-946-4004
Mailing Address - Street 1:15995 TUSCOLA RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2159
Mailing Address - Country:US
Mailing Address - Phone:760-946-4004
Mailing Address - Fax:760-946-4944
Practice Address - Street 1:15995 TUSCOLA RD
Practice Address - Street 2:SUITE 203
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2159
Practice Address - Country:US
Practice Address - Phone:760-946-4004
Practice Address - Fax:760-946-4944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA694922084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ29644ZMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
CADD4376Medicare ID - Type UnspecifiedRAILROAD MEDICARE