Provider Demographics
NPI:1366850091
Name:VICTOR VALLEY HOSPITAL ACQUISITION INC
Entity Type:Organization
Organization Name:VICTOR VALLEY HOSPITAL ACQUISITION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:R
Authorized Official - Last Name:LAVALLEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-843-6125
Mailing Address - Street 1:15248 ELEVENTH ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-3704
Mailing Address - Country:US
Mailing Address - Phone:760-843-6101
Mailing Address - Fax:760-843-6056
Practice Address - Street 1:12384 PALMDALE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-8506
Practice Address - Country:US
Practice Address - Phone:760-843-6101
Practice Address - Fax:760-843-6056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-25
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000218282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT30517FMedicaid
CA050517Medicare PIN