Basic Information
Provider Information | |||||||||
NPI: | 1629230032 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KAISER FOUNDATION HOSPITALS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KAISER FOUNDATION HOSPITAL - MORENO VALLEY PSYCH UNIT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 27300 IRIS AVE | ||||||||
Address2: |   | ||||||||
City: | MORENO VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 925554802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9512430811 | ||||||||
FaxNumber: | 9512432005 | ||||||||
Practice Location | |||||||||
Address1: | 27300 IRIS AVE | ||||||||
Address2: |   | ||||||||
City: | MORENO VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 925554802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9512430811 | ||||||||
FaxNumber: | 9512432005 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/26/2008 | ||||||||
LastUpdateDate: | 05/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WILLET | ||||||||
AuthorizedOfficialFirstName: | VITA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9513534601 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 550000810 | CA | Y |   | Hospital Units | Psychiatric Unit |   |
No ID Information.