Provider Demographics
NPI:1427595412
Name:HI-DESERT FAMILY MEDICAL CLINIC
Entity Type:Organization
Organization Name:HI-DESERT FAMILY MEDICAL CLINIC
Other - Org Name:HI DESERT FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:KASKO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:760-366-7555
Mailing Address - Street 1:7350 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-3246
Mailing Address - Country:US
Mailing Address - Phone:760-369-3069
Mailing Address - Fax:
Practice Address - Street 1:7350 CHURCH ST
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-3246
Practice Address - Country:US
Practice Address - Phone:760-369-3069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY HEALTH CENTER OF JOSHUA TREE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA058941Medicare UPIN