Basic Information
| Provider Information | |||||||||
| NPI: | 1861715922 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MENTAL HEALTH SUBSTANCE ABUSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 623 N MAIN ST STE D11 | ||||||||
| Address2: | |||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928801408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517372962 | ||||||||
| FaxNumber: | 9517372783 | ||||||||
| Practice Location | |||||||||
| Address1: | 623 N MAIN ST STE D11 | ||||||||
| Address2: | |||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928801408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517372962 | ||||||||
| FaxNumber: | 9517372783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2010 | ||||||||
| LastUpdateDate: | 03/03/2010 | ||||||||
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| AuthorizedOfficialLastName: | MADRIGAL | ||||||||
| AuthorizedOfficialFirstName: | LUPE (GUADALUPE) | ||||||||
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| AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 9517372962 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 33023DN | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.