Basic Information
| Provider Information | |||||||||
| NPI: | 1366753683 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 360 MIND | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7111 | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904067111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105827450 | ||||||||
| FaxNumber: | 3105827495 | ||||||||
| Practice Location | |||||||||
| Address1: | 1328 22ND ST | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105827450 | ||||||||
| FaxNumber: | 3105827495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2010 | ||||||||
| LastUpdateDate: | 07/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | KERR | ||||||||
| AuthorizedOfficialFirstName: | KATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3105827312 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | C53853 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 207Y00000X | G88653 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 207T00000X | G77318 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.