Healthcare Provider Details

I. General information

NPI: 1023954823
Provider Name (Legal Business Name): CRESTLINE PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2026
Last Update Date: 04/25/2026
Certification Date: 04/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11332 MOUNTAIN VIEW AVE STE C
LOMA LINDA CA
92354-3854
US

IV. Provider business mailing address

PO BOX 2141
REDLANDS CA
92373-0701
US

V. Phone/Fax

Practice location:
  • Phone: 909-487-9300
  • Fax:
Mailing address:
  • Phone: 909-487-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRYAN MARTIN WICK
Title or Position: PRESIDENT
Credential: MD
Phone: 909-487-9300