Healthcare Provider Details

I. General information

NPI: 1770686347
Provider Name (Legal Business Name): SOCAL PSYCHIATRIC MEDICAL GROUP, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 WILSHIRE BLVD SUITE 930
LOS ANGELES CA
90010-1438
US

IV. Provider business mailing address

3250 WILSHIRE BLVD SUITE 930
LOS ANGELES CA
90010-1438
US

V. Phone/Fax

Practice location:
  • Phone: 213-739-0019
  • Fax: 213-739-0091
Mailing address:
  • Phone: 213-739-0019
  • Fax: 213-739-0091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: STUART L ZUBRICK
Title or Position: MANAGING PARTNER
Credential: PHD
Phone: 213-739-0019