Healthcare Provider Details

I. General information

NPI: 1780120436
Provider Name (Legal Business Name): SIGMA BETA XI INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14340 ELSWORTH ST B112/113
MORENO VALLEY CA
92553-9019
US

IV. Provider business mailing address

14340 ELSWORTH ST B112/113
MORENO VALLEY CA
92553-9019
US

V. Phone/Fax

Practice location:
  • Phone: 951-247-1700
  • Fax:
Mailing address:
  • Phone: 951-247-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: COREY JACKSON
Title or Position: CEO
Credential:
Phone: 951-247-1700