Healthcare Provider Details

I. General information

NPI: 1164296653
Provider Name (Legal Business Name): LINDENHURST VPAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2023
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16365 PICK PL
RIVERSIDE CA
92504-5638
US

IV. Provider business mailing address

1057 E IMPERIAL HWY # 226
PLACENTIA CA
92870-1717
US

V. Phone/Fax

Practice location:
  • Phone: 714-887-3816
  • Fax: 209-203-1061
Mailing address:
  • Phone: 714-887-3816
  • Fax: 209-203-1061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANGELIKA PANOVA
Title or Position: EXECUTIVE MANAGER
Credential: PMHNP-RN, LMFT
Phone: 714-887-3816