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General NPI Number Information
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NPI Number | 1750835013
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Entity Type | Organization
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Legal Business Name | LOMA LINDA PSYCHIATRIC MEDICAL GROUP
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Dates
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Enumeration Date | 08/04/2016
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Last Update Date | 01/10/2025
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Provider Practice Location Address
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Address Line | 1200 CALIFORNIA ST STE 140
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City | REDLANDS
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State | CA
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Zip | 92374-2946
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Country | US
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Telephone | 909-880-4200
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1303
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City | LOMA LINDA
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State | CA
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Zip | 92354-1303
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Country | US
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Telephone | 909-880-4200
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Fax | 888-505-0620
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Authorized Official
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Title or Position | PARTNER
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Name | LIBERTY MACIAS
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Credential | NP
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Telephone | 909-792-6886
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 95002264
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 56486
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License Number State | CA
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