Basic Information
| Provider Information | |||||||||
| NPI: | 1053776484 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUBLIC GUARDIAN | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3625 14TH ST. | ||||||||
| Address2: | P.O. BOX 1405 | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519551540 | ||||||||
| FaxNumber: | 9519551610 | ||||||||
| Practice Location | |||||||||
| Address1: | 3625 14TH ST. | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519551540 | ||||||||
| FaxNumber: | 9519551610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2015 | ||||||||
| LastUpdateDate: | 12/30/2015 | ||||||||
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| AuthorizedOfficialLastName: | PEAY | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DEPUTY PUBLIC GUARDIAN | ||||||||
| AuthorizedOfficialTelephone: | 9519551540 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.