Healthcare Provider Details

I. General information

NPI: 1265588909
Provider Name (Legal Business Name): INLAND PSYCHIATRIC MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8710 MONROE CT SUITE 150
RANCHO CUCAMONGA CA
91730-4883
US

IV. Provider business mailing address

1809 W REDLANDS BLVD
REDLANDS CA
92373-8054
US

V. Phone/Fax

Practice location:
  • Phone: 909-941-4870
  • Fax: 909-941-4875
Mailing address:
  • Phone: 909-307-1320
  • Fax: 909-798-3607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SYAM P KUNAM
Title or Position: CEO
Credential: M.D.
Phone: 909-335-3026