Basic Information
| Provider Information | |||||||||
| NPI: | 1780730689 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERIM PSYCHIATRIC CARE, MEDICAL CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | IPC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9327 FAIRWAY VIEW PL | ||||||||
| Address2: | STE 110 | ||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917300968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099453330 | ||||||||
| FaxNumber: | 9099451031 | ||||||||
| Practice Location | |||||||||
| Address1: | 9327 FAIRWAY VIEW PL | ||||||||
| Address2: | STE 110 | ||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917300968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099453330 | ||||||||
| FaxNumber: | 9099451031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 04/12/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NAKAI | ||||||||
| AuthorizedOfficialFirstName: | BHUPINDER | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9099453330 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFT32483 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | MFC34041 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | MFC32911 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 174400000X | A534670 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | C50549 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | LCS25407 | 01 | CA | CA BOARD OF SOCIAL WORKERS | OTHER | 00A534672 | 05 | CA | MEDICAID | PSY21662 | 01 | CA | CA BOARD OF PSYCHOLOGY | OTHER | 00C505490 | 05 | CA | MEDICAID |