Provider Demographics
NPI:1942529482
Name:HIGH DESERT PRIMARY CARE MEDICAL GROUP
Entity Type:Organization
Organization Name:HIGH DESERT PRIMARY CARE MEDICAL GROUP
Other - Org Name:HIGH DESERT PRIMARY CARE - APPLE VALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. DIRECTOR OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-625-2990
Mailing Address - Street 1:5626 OBERLIN DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19333 BEAR VALLEY RD
Practice Address - Street 2:101
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-5148
Practice Address - Country:US
Practice Address - Phone:760-240-3784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDVANTX, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-24
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49522332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site