Provider Demographics
NPI:1114094141
Name:TRUXTUN PSYCHIATRIC MEDICAL GROUP
Entity Type:Organization
Organization Name:TRUXTUN PSYCHIATRIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAKREPATNA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MANOHARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-323-6410
Mailing Address - Street 1:6001 TRUXTUN AVE
Mailing Address - Street 2:SUITE #160
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-0679
Mailing Address - Country:US
Mailing Address - Phone:661-323-6410
Mailing Address - Fax:
Practice Address - Street 1:6001 TRUXTUN AVE
Practice Address - Street 2:SUITE #160
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-0679
Practice Address - Country:US
Practice Address - Phone:661-323-6410
Practice Address - Fax:661-323-7631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34791174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA88264Medicare UPIN
CAZZZ14138ZMedicare PIN