Healthcare Provider Details

I. General information

NPI: 1891323770
Provider Name (Legal Business Name): BEHAVIORAL INNOVATION IN NURSING PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14023 PARAMOUNT BLVD
PARAMOUNT CA
90723-2605
US

IV. Provider business mailing address

14023 PARAMOUNT BLVD
PARAMOUNT CA
90723-2605
US

V. Phone/Fax

Practice location:
  • Phone: 562-331-8881
  • Fax: 562-988-3373
Mailing address:
  • Phone: 562-331-8881
  • Fax: 562-988-3373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: FELICIA PONDER
Title or Position: ADMINISTRATOR
Credential:
Phone: 951-315-1265