Provider Demographics
NPI:1639405004
Name:HIGH DESERT FAMILY MEDICAL CLINIC
Entity type:Organization
Organization Name:HIGH DESERT FAMILY MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:KASKO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:760-369-3069
Mailing Address - Street 1:PO BOX 1220
Mailing Address - Street 2:
Mailing Address - City:JOSHUA TREE
Mailing Address - State:CA
Mailing Address - Zip Code:92252-0810
Mailing Address - Country:US
Mailing Address - Phone:760-369-3069
Mailing Address - Fax:760-369-3072
Practice Address - Street 1:7350 CHURCH ST
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-3246
Practice Address - Country:US
Practice Address - Phone:760-369-3069
Practice Address - Fax:760-369-3072
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY HEALTH CENTER OF JOSHUA TREE INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-20
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA553845OtherMEDICARE IDENTIFICATION NUMBER
CA1867739Medicaid