Provider Demographics
NPI:1083924674
Name:CALIFORNIA INSTITUTE FOR BEHAVIORAL MEDICINE, A MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CALIFORNIA INSTITUTE FOR BEHAVIORAL MEDICINE, A MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:323-964-0866
Mailing Address - Street 1:5757 WILSHIRE BLVD
Mailing Address - Street 2:#6
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-5810
Mailing Address - Country:US
Mailing Address - Phone:323-964-0866
Mailing Address - Fax:323-964-0868
Practice Address - Street 1:5757 WILSHIRE BLVD
Practice Address - Street 2:#6
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-5810
Practice Address - Country:US
Practice Address - Phone:323-964-0866
Practice Address - Fax:323-964-0868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW1588Medicare PIN