=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164122800
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCINTADEL LIBERTY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2023
-----------------------------------------------------
Last Update Date | 04/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6833 INDIANA AVE STE 208
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92506-4223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-422-6853
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 921 N MILLIKEN AVE # 1176
-----------------------------------------------------
City | ONTARIO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91764-5083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-422-6853
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. VIJAY CHANDRAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 213-422-6853
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0802X
-----------------------------------------------------
Taxonomy Name | Addiction Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------