Heritage Victor Valley Medical Group

Primary specialty

Non-Pharmacy Dispensing SiteTaxonomy code 332900000X

License

54968 Issued in CA

Legal business name

HERITAGE VICTOR VALLEY MEDICAL GROUP

Practice address

12408 Hesperia Rd
#2
Victorville, CA 92395-7718

Phone

(760) 245-4747

NPI assigned

Oct 23, 2009

Organization subpart

Yes

Parent organization

MEDVANTX, INC.As reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Kenny Heine

Title

VP of Operations

Phone

(858) 625-2990

Specialties & licenses 1

Addresses

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Part of

Tri - State Medical Group Inc

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1256256000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1448841600000",
    "number": "1649506759",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9276 SCRANTON RD",
            "address_2": "SUITE 100",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921217701"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12408 HESPERIA RD",
            "address_2": "#2",
            "city": "VICTORVILLE",
            "state": "CA",
            "postal_code": "923957718",
            "telephone_number": "760-245-4747"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HERITAGE VICTOR VALLEY MEDICAL GROUP",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MEDVANTX, INC.",
        "enumeration_date": "2009-10-23",
        "last_updated": "2015-11-30",
        "status": "A",
        "authorized_official_last_name": "HEINE",
        "authorized_official_first_name": "KENNY",
        "authorized_official_title_or_position": "VP OF OPERATIONS",
        "authorized_official_telephone_number": "858-625-2990"
    },
    "taxonomies": [
        {
            "code": "332900000X",
            "taxonomy_group": "",
            "desc": "Non-Pharmacy Dispensing Site",
            "state": "CA",
            "license": "54968",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Nichole Christine Henderson
• Carli Hendricks
• Robert James Hepp
• Ruphil Maria Hepp, PT
• Adrian Herek
• Heritage Victor Valley Medical Group
• Kristy Tamoria Hermosilla
• Adriana Hermosillo, M.S., LMFT
• Balbina Hernandez Morales
• Alexis D Hernandez

• Non-Pharmacy Dispensing Site in Victorville, CA
• Providers in Victorville, CA by specialty
• Non-Pharmacy Dispensing Site in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 30, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.