Provider Demographics
NPI:1750835013
Name:LOMA LINDA PSYCHIATRIC MEDICAL GROUP
Entity Type:Organization
Organization Name:LOMA LINDA PSYCHIATRIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:LIBERTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MACIAS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:909-894-4260
Mailing Address - Street 1:26070 LUGO DR
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-6507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:888-505-0620
Practice Address - Street 1:26070 LUGO DR
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-6507
Practice Address - Country:US
Practice Address - Phone:909-894-4260
Practice Address - Fax:888-505-0620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-04
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56486261QM1300X
CA95002264363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA127629OtherUIN