Provider Demographics
NPI:1376680124
Name:WESTSIDE PREMIER MED GRP
Entity Type:Organization
Organization Name:WESTSIDE PREMIER MED GRP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:AMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-949-1489
Mailing Address - Street 1:17330 BEAR VALLEY RD STE 105
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395
Mailing Address - Country:US
Mailing Address - Phone:760-245-8182
Mailing Address - Fax:760-245-2123
Practice Address - Street 1:17330 BEAR VALLEY RD STE 105
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395
Practice Address - Country:US
Practice Address - Phone:760-245-8182
Practice Address - Fax:760-245-2123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC21523111N00000X
CADC27666111N00000X
CAA36514207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty