Provider Demographics
NPI:1710199674
Name:ANTELOPE VALLEY COMMUNITY CLINIC
Entity Type:Organization
Organization Name:ANTELOPE VALLEY COMMUNITY CLINIC
Other - Org Name:ANTELOPE VALLEY COMMUNITY CLINIC - MOBILE HEALTH CLINIC I
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:661-942-2391
Mailing Address - Street 1:45074 10TH ST W
Mailing Address - Street 2:SUITE 109
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2371
Mailing Address - Country:US
Mailing Address - Phone:661-942-2391
Mailing Address - Fax:661-902-6839
Practice Address - Street 1:45104 10TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2310
Practice Address - Country:US
Practice Address - Phone:661-942-2391
Practice Address - Fax:661-902-6839
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANTELOPE VALLEY COMMUNITY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-04
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA060000428261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM70633HOtherMEDI-CAL
CACT556AOtherMEDICARE PTAN
CA551056Medicare Oscar/Certification