Provider Demographics
NPI:1336172949
Name:ANTELOPE VALLEY NEPHROLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:ANTELOPE VALLEY NEPHROLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNG
Authorized Official - Middle Name:C
Authorized Official - Last Name:YANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-948-1388
Mailing Address - Street 1:PO BOX 2768
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93539-2768
Mailing Address - Country:US
Mailing Address - Phone:661-948-8309
Mailing Address - Fax:661-948-8907
Practice Address - Street 1:1759 W AVENUE J # 101
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2703
Practice Address - Country:US
Practice Address - Phone:661-948-1388
Practice Address - Fax:661-948-1223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954053663OtherTAX ID
CAGR0002830Medicaid
CAW6508Medicare PIN
CAZZZ15456ZMedicare PIN