Provider Demographics
NPI:1548003015
Name:OC GEROPSYCHIATRIC MEDICAL GROUP
Entity type:Organization
Organization Name:OC GEROPSYCHIATRIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, SECRETARY, AND TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:THU
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:714-487-9724
Mailing Address - Street 1:16478 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-7860
Mailing Address - Country:US
Mailing Address - Phone:714-487-9724
Mailing Address - Fax:
Practice Address - Street 1:6000 CAMINO REAL
Practice Address - Street 2:SUITE B
Practice Address - City:JURUPA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92509
Practice Address - Country:US
Practice Address - Phone:714-487-9724
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty