Healthcare Provider Details

I. General information

NPI: 1306072426
Provider Name (Legal Business Name): INTEGRATED MIND INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2009
Last Update Date: 03/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24949 PROSPECT AVE
LOMA LINDA CA
92354-2811
US

IV. Provider business mailing address

24550 LAWTON AVE
LOMA LINDA CA
92354-3336
US

V. Phone/Fax

Practice location:
  • Phone: 909-796-4774
  • Fax: 909-796-2774
Mailing address:
  • Phone: 909-796-4774
  • Fax: 909-796-2774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberA97080
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA97080
License Number StateCA

VIII. Authorized Official

Name: DR. WARRIS RICHARD WALAYAT SR.
Title or Position: CHAIRMAN
Credential: M.D.
Phone: 909-796-4774