Healthcare Provider Details

I. General information

NPI: 1740689694
Provider Name (Legal Business Name): MIND & BODY TREATMENT AND RESEARCH INSTITUTE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2014
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 DIVISION ST 200
RIVERSIDE CA
92506-3257
US

IV. Provider business mailing address

3060 EL CERRITO PLZ SUITE 266
EL CERRITO CA
94530-4011
US

V. Phone/Fax

Practice location:
  • Phone: 951-300-4905
  • Fax:
Mailing address:
  • Phone: 510-685-2022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberA94223
License Number StateCA

VIII. Authorized Official

Name: DR. RAJAGOPAL KEERTHY SUNDER
Title or Position: OWNER
Credential: M.D.
Phone: 510-685-2022