Healthcare Provider Details

I. General information

NPI: 1396337150
Provider Name (Legal Business Name): INLAND PSYCHIATRIC MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12442 LIMONITE AVE UNIT 104
EASTVALE CA
91752-2467
US

IV. Provider business mailing address

1809 W REDLANDS BLVD
REDLANDS CA
92373-8054
US

V. Phone/Fax

Practice location:
  • Phone: 951-344-4451
  • Fax: 951-416-2252
Mailing address:
  • Phone: 909-289-4075
  • Fax: 909-363-8233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 6
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: AMBER GUTIERREZ
Title or Position: PROVIDER RELATIONS
Credential:
Phone: 909-289-4075