Provider Demographics
NPI:1437273521
Name:THE CAROLYN E. WYLIE CENTER
Entity Type:Organization
Organization Name:THE CAROLYN E. WYLIE CENTER
Other - Org Name:THE WYLIE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-683-5193
Mailing Address - Street 1:4164 BROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-3400
Mailing Address - Country:US
Mailing Address - Phone:951-683-5193
Mailing Address - Fax:951-683-6019
Practice Address - Street 1:4164 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3400
Practice Address - Country:US
Practice Address - Phone:951-683-5193
Practice Address - Fax:951-683-6019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33BAA0OtherOTHER
CA33BA00OtherOTHER