Healthcare Provider Details

I. General information

NPI: 1366753683
Provider Name (Legal Business Name): 360 MIND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1328 22ND ST
SANTA MONICA CA
90404-2032
US

IV. Provider business mailing address

PO BOX 7111
SANTA MONICA CA
90406-7111
US

V. Phone/Fax

Practice location:
  • Phone: 310-582-7450
  • Fax: 310-582-7495
Mailing address:
  • Phone: 310-582-7450
  • Fax: 310-582-7495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberC53853
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberG88653
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberG77318
License Number StateCA

VIII. Authorized Official

Name: MS. KATHERINE L KERR
Title or Position: VP OF OPERATIONS
Credential:
Phone: 310-582-7312