MEDICARE: ANTEDAR PSYCHIATRIC NURSING PROFESSIONAL SERVICES, INC

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

General Provider Information

NPI Number	:	1871362186
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANTEDAR PSYCHIATRIC NURSING PROFESSIONAL SERVICES, INC

Provider Business Mailing Address
First Line	:	PO BOX 51927
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92517-2927
Country	:	US
Telephone Number	:	951-236-9430
Fax Number	:

Provider Business Practice Location Address
First Line	:	6860 BROCKTON AVE
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-3821
Country	:	US
Telephone Number	:	951-236-9430
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	BARIASA KANABOLO
Credential	:	NP
Telephone Number	:	951-236-9430

Provider Enumeration Date	:	12/28/2023
Last Update Date	:	12/29/2023

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