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General NPI Number Information
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NPI Number | 1770024119
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Entity Type | Organization
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Legal Business Name | DEEP WATERS PSYCHIATRIC MEDICAL GROUP, INC.
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Dates
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Enumeration Date | 03/18/2017
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Last Update Date | 03/18/2017
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Provider Practice Location Address
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Address Line | 9531 PITTSBURGH AVE
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-6008
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Country | US
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Telephone | 909-256-8360
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 11387
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City | SAN BERNARDINO
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State | CA
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Zip | 92423-1387
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Country | US
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Telephone | 888-984-7888
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Fax | 888-984-7888
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Authorized Official
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Title or Position | CORPORATE SECRETARY
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Name | MRS. CAROLYN ANNELLE MAURER
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Credential |
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Telephone | 888-984-7888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State | CA
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