Provider Demographics
NPI:1548226491
Name:THE WOMEN'S CLINIC A MEDICAL GROUP OF THE ANTELOPE VALLEY
Entity Type:Organization
Organization Name:THE WOMEN'S CLINIC A MEDICAL GROUP OF THE ANTELOPE VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANNINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-949-5899
Mailing Address - Street 1:44105 N. 15TH ST W
Mailing Address - Street 2:SUITE 304
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534
Mailing Address - Country:US
Mailing Address - Phone:661-949-5899
Mailing Address - Fax:661-949-5832
Practice Address - Street 1:44105 N. 15TH ST W
Practice Address - Street 2:SUITE 304
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534
Practice Address - Country:US
Practice Address - Phone:661-949-5899
Practice Address - Fax:661-949-5832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA88415OtherDR GUPTA STATE LICENSE
CA00G451540Medicaid
CA00A380080Medicaid
CAA88415OtherDR GUPTA STATE LICENSE
CAA28509Medicare UPIN
CA00G451540Medicaid
CAA49914Medicare ID - Type UnspecifiedDR BERMAN