Healthcare Provider Details

I. General information

NPI: 1700668845
Provider Name (Legal Business Name): EAGLEVIEWPSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2023
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 J ST STE 400
SACRAMENTO CA
95814-2394
US

IV. Provider business mailing address

8765 HERITAGE HILL DR
ELK GROVE CA
95624-3945
US

V. Phone/Fax

Practice location:
  • Phone: 916-999-1418
  • Fax: 916-288-8886
Mailing address:
  • Phone: 916-999-1418
  • Fax: 916-288-8886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MANVIR PANNU
Title or Position: OWNER
Credential:
Phone: 916-999-1418