Provider Demographics
NPI:1770024119
Name:DEEP WATERS PSYCHIATRIC MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:DEEP WATERS PSYCHIATRIC MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:ANNELLE
Authorized Official - Last Name:MAURER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-984-7888
Mailing Address - Street 1:PO BOX 11387
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-1387
Mailing Address - Country:US
Mailing Address - Phone:888-984-7888
Mailing Address - Fax:888-984-7888
Practice Address - Street 1:9531 PITTSBURGH AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6008
Practice Address - Country:US
Practice Address - Phone:909-256-8360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-18
Last Update Date:2017-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty