Healthcare Provider Details

I. General information

NPI: 1215850904
Provider Name (Legal Business Name): LLPMG REDLANDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CALIFORNIA ST STE 140
REDLANDS CA
92374-2946
US

IV. Provider business mailing address

1200 CALIFORNIA ST STE 140
REDLANDS CA
92374-2946
US

V. Phone/Fax

Practice location:
  • Phone: 909-792-6262
  • Fax: 909-550-1928
Mailing address:
  • Phone: 909-792-6262
  • Fax: 909-550-1928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LIBERTY OLIVE MACIAS
Title or Position: CEO
Credential: NP
Phone: 909-900-6465