Healthcare Provider Details

I. General information

NPI: 1376184168
Provider Name (Legal Business Name): PEAK WELLNESS PSYCHIATRY, A PROFESSIONAL NURSING CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8880 RIO SAN DIEGO DR STE 800
SAN DIEGO CA
92108-1642
US

IV. Provider business mailing address

440 N BARRANCA AVE # 6619
COVINA CA
91723-1722
US

V. Phone/Fax

Practice location:
  • Phone: 888-909-8676
  • Fax:
Mailing address:
  • Phone: 888-909-8676
  • Fax: 855-940-1848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: RYAN D THEBO
Title or Position: OWNER OF ENTITY
Credential: PMHNP-BC
Phone: 888-909-8676