Provider Demographics
NPI:1932491271
Name:ST MARY LLC
Entity Type:Organization
Organization Name:ST MARY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:F
Authorized Official - Last Name:BISHARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-787-4885
Mailing Address - Street 1:6896 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2843
Mailing Address - Country:US
Mailing Address - Phone:951-787-4885
Mailing Address - Fax:951-787-4962
Practice Address - Street 1:6896 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2843
Practice Address - Country:US
Practice Address - Phone:951-787-4885
Practice Address - Fax:951-787-4962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A432060261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder