Healthcare Provider Details

I. General information

NPI: 1295486173
Provider Name (Legal Business Name): MAC HOPE MEDICAL AND MENTAL HEALTH CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 S MOUNT VERNON AVE STE 7A
COLTON CA
92324-3926
US

IV. Provider business mailing address

6279 SANDHILL PL
RANCHO CUCAMONGA CA
91739-2600
US

V. Phone/Fax

Practice location:
  • Phone: 760-241-6044
  • Fax:
Mailing address:
  • Phone: 909-912-4310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083C0008X
TaxonomyClinical Informatics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHY ADINMA
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 909-912-4310