Provider Demographics
NPI:1134986995
Name:LB SEA PSYCHIATRY A MEDICAL CORPORATION
Entity type:Organization
Organization Name:LB SEA PSYCHIATRY A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEDARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-512-6475
Mailing Address - Street 1:3711 LONG BEACH BLVD UNIT 4535
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3315
Mailing Address - Country:US
Mailing Address - Phone:562-512-6475
Mailing Address - Fax:562-512-9012
Practice Address - Street 1:1777 N BELLFLOWER BLVD STE 102
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-4019
Practice Address - Country:US
Practice Address - Phone:562-512-6475
Practice Address - Fax:562-512-9012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-28
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty