Provider Demographics
NPI:1265639660
Name:KAISER PERMANENTE
Entity Type:Organization
Organization Name:KAISER PERMANENTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR III
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:MELTON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:951-601-6171
Mailing Address - Street 1:12815 HEACOCK ST
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-3116
Mailing Address - Country:US
Mailing Address - Phone:051-601-6174
Mailing Address - Fax:951-601-6224
Practice Address - Street 1:12815 HEACOCK ST
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3116
Practice Address - Country:US
Practice Address - Phone:051-601-6174
Practice Address - Fax:951-601-6224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC17474261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)