Basic Information
| Provider Information | |||||||||
| NPI: | 1962755900 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIND CARE MEDICAL GROUP, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | M&M PSYCHIATRY | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 11351 BASKERVILLE RD | ||||||||
| Address2: | |||||||||
| City: | ROSSMOOR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907202927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624303086 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1907 BOYS REPUBLIC DR | ||||||||
| Address2: | |||||||||
| City: | CHINO HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917095447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096281217 | ||||||||
| FaxNumber: | 9096274129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2012 | ||||||||
| LastUpdateDate: | 10/15/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARQUEZ | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | GUADALUPE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5628330496 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 20A8470 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 20A8470 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.