=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801366083
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE DEPARTMENT OF PSYCHIATRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2018
-----------------------------------------------------
Last Update Date | 11/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20350 SW BIRCH ST
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-1713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-509-2230
-----------------------------------------------------
Fax | 949-250-9177
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 31001-2473
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91110-2473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-456-3760
-----------------------------------------------------
Fax | 714-456-2398
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DELEGATED OFFICIAL
-----------------------------------------------------
Name | JUAN A MENDOZA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-456-2986
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084S0012X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------