Provider Demographics
NPI:1114912979
Name:ANTELOPE VALLEY NEUROSCIENCE
Entity Type:Organization
Organization Name:ANTELOPE VALLEY NEUROSCIENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ABDALLAH
Authorized Official - Middle Name:S
Authorized Official - Last Name:FARRUKH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-945-6931
Mailing Address - Street 1:42135 10TH ST W
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-7095
Mailing Address - Country:US
Mailing Address - Phone:661-945-6931
Mailing Address - Fax:661-945-4592
Practice Address - Street 1:42135 10TH ST W
Practice Address - Street 2:SUITE 301
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-7095
Practice Address - Country:US
Practice Address - Phone:661-945-6931
Practice Address - Fax:661-945-4592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207T00000X, 2084N0400X
CANP20677363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ83620ZMedicaid
CAHW5872Medicare ID - Type Unspecified
CAZZZ83620ZMedicaid