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General NPI Number Information
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NPI Number | 1932491271
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Entity Type | Organization
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Legal Business Name | ST MARY LLC
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Dates
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Enumeration Date | 05/04/2011
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Last Update Date | 05/04/2011
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Provider Practice Location Address
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Address Line | 6896 MAGNOLIA AVE
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City | RIVERSIDE
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State | CA
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Zip | 92506-2843
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Country | US
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Telephone | 951-787-4885
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Fax | 951-787-4962
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Provider Business Mailing Address
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Address Line | 6896 MAGNOLIA AVE
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City | RIVERSIDE
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State | CA
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Zip | 92506-2843
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Country | US
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Telephone | 951-787-4885
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Fax | 951-787-4962
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. MICHAEL F BISHARA
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Credential | M.D.
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Telephone | 951-787-4885
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 00A432060
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License Number State | CA
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