1407861818 NPI number — MOJAVE RADIATION ONCOLOGY MEDICAL GROUP, INC.

Table of content: (NPI 1407861818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407861818 NPI number — MOJAVE RADIATION ONCOLOGY MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOJAVE RADIATION ONCOLOGY MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407861818
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 WOODMONT BLVD STE 500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37205-2245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-492-6695
Provider Business Mailing Address Fax Number:
949-612-8255

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18280 SISKIYOU RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APPLE VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92307-1413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-242-1372
Provider Business Practice Location Address Fax Number:
760-242-1127
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ALQAISI
Authorized Official First Name:
MUNTHER
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PROVIDER
Authorized Official Telephone Number:
562-492-6695

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9673134 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0050110 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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