Provider Demographics
NPI:1861715922
Name:MENTAL HEALTH SUBSTANCE ABUSE
Entity type:Organization
Organization Name:MENTAL HEALTH SUBSTANCE ABUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:LUPE (GUADALUPE)
Authorized Official - Middle Name:
Authorized Official - Last Name:MADRIGAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-737-2962
Mailing Address - Street 1:623 N MAIN ST STE D11
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92880-1408
Mailing Address - Country:US
Mailing Address - Phone:951-737-2962
Mailing Address - Fax:951-737-2783
Practice Address - Street 1:623 N MAIN ST STE D11
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92880-1408
Practice Address - Country:US
Practice Address - Phone:951-737-2962
Practice Address - Fax:951-737-2783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33023DN251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health