Healthcare Provider Details

I. General information

NPI: 1194247072
Provider Name (Legal Business Name): DEEP PATEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6711 ARLINGTON AVE STE B
RIVERSIDE CA
92504-1966
US

IV. Provider business mailing address

6538 GOLDEN CLUB DR
MIRA LOMA CA
91752-4352
US

V. Phone/Fax

Practice location:
  • Phone: 951-352-4964
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95006804
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: