Provider Demographics
NPI:1346327517
Name:LA MER PSYCHIATRIC MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:LA MER PSYCHIATRIC MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-388-8330
Mailing Address - Street 1:PO BOX 201
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93011-0201
Mailing Address - Country:US
Mailing Address - Phone:805-388-8330
Mailing Address - Fax:805-388-8030
Practice Address - Street 1:1901 OUTLET CENTER DR
Practice Address - Street 2:SUITE 220
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-0663
Practice Address - Country:US
Practice Address - Phone:805-388-8330
Practice Address - Fax:805-388-8030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16564Medicare ID - Type Unspecified