Healthcare Provider Details

I. General information

NPI: 1750835013
Provider Name (Legal Business Name): LOMA LINDA PSYCHIATRIC MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2016
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CALIFORNIA ST STE 140
REDLANDS CA
92374-2946
US

IV. Provider business mailing address

PO BOX 1303
LOMA LINDA CA
92354-1303
US

V. Phone/Fax

Practice location:
  • Phone: 909-880-4200
  • Fax:
Mailing address:
  • Phone: 909-880-4200
  • Fax: 888-505-0620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number56486
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95002264
License Number StateCA

VIII. Authorized Official

Name: LIBERTY MACIAS
Title or Position: PARTNER
Credential: NP
Phone: 909-792-6886