Healthcare Provider Details

I. General information

NPI: 1922642479
Provider Name (Legal Business Name): IMPERIAL COUNTY COMMUNTY MENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 E 5TH ST
HOLTVILLE CA
92250-1514
US

IV. Provider business mailing address

3218 E HOLT AVE STE 200
WEST COVINA CA
91791-2310
US

V. Phone/Fax

Practice location:
  • Phone: 626-991-7383
  • Fax:
Mailing address:
  • Phone: 626-991-7383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. EPIFANIA V NICOLAS
Title or Position: PRESIDENT
Credential: DDS
Phone: 714-906-9116