MEDICARE: LOMA LINDA PSYCHIATRIC MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	95002264	CA
2	261QM1300X	Multi-Specialty Clinic/Center	56486	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	127629	OTHER	CA	UIN

General Provider Information

NPI Number	:	1750835013
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOMA LINDA PSYCHIATRIC MEDICAL GROUP

Provider Business Mailing Address
First Line	:	PO BOX 1303
Second Line	:
City	:	LOMA LINDA
State	:	CA
Zip	:	92354-1303
Country	:	US
Telephone Number	:	909-880-4200
Fax Number	:	888-505-0620

Provider Business Practice Location Address
First Line	:	1200 CALIFORNIA ST STE 140
Second Line	:
City	:	REDLANDS
State	:	CA
Zip	:	92374-2946
Country	:	US
Telephone Number	:	909-880-4200
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	LIBERTY MACIAS
Credential	:	NP
Telephone Number	:	909-792-6886

Provider Enumeration Date	:	08/04/2016
Last Update Date	:	01/10/2025

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