Provider Demographics
NPI:1790198299
Name:ANTELOPE VALLEY MEDICAL GROUP
Entity Type:Organization
Organization Name:ANTELOPE VALLEY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-618-8119
Mailing Address - Street 1:540 W PALMDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-4232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:357 E BALFOUR AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-0709
Practice Address - Country:US
Practice Address - Phone:559-434-0203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA667882207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty