1730306499 NPI number — ANTELOPE VALLEY REHABILITATION CENTERS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730306499 NPI number — ANTELOPE VALLEY REHABILITATION CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANTELOPE VALLEY REHABILITATION CENTERS
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:
1730306499
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ACTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93510-0025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-269-0062
Provider Business Mailing Address Fax Number:
661-269-0427

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44900 60TH ST W
Provider Second Line Business Practice Location Address:
CHP TRAILER
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93536-7618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-945-8458
Provider Business Practice Location Address Fax Number:
661-945-8248
Provider Enumeration Date:
04/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HASELTINE
Authorized Official First Name:
GREG
Authorized Official Middle Name:
Authorized Official Title or Position:
INTERIM EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
661-269-0074

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6767 . This is a "MEDI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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