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General NPI Number Information
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NPI Number | 1548003015
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Entity Type | Organization
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Legal Business Name | OC GEROPSYCHIATRIC MEDICAL GROUP
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Dates
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Enumeration Date | 06/13/2024
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Last Update Date | 06/13/2024
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Provider Practice Location Address
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Address Line | 6000 CAMINO REAL SUITE B
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City | JURUPA VALLEY
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State | CA
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Zip | 92509
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Country | US
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Telephone | 714-487-9724
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Fax |
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Provider Business Mailing Address
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Address Line | 16478 BEACH BLVD
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City | WESTMINSTER
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State | CA
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Zip | 92683-7860
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Country | US
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Telephone | 714-487-9724
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Fax |
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Authorized Official
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Title or Position | DIRECTOR, SECRETARY, AND TREASURER
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Name | THU PHAN
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Credential | NP
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Telephone | 714-487-9724
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0805X
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Taxonomy Name | Geriatric Psychiatry Physician
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License Number |
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License Number State |
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