1023586716 NPI number — MIND OASIS PSYCHIATRY, A PROFESSIONAL NURSING CORPORATION

Table of content: (NPI 1023586716)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023586716 NPI number — MIND OASIS PSYCHIATRY, A PROFESSIONAL NURSING CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
MIND OASIS PSYCHIATRY, A PROFESSIONAL NURSING CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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NPI Number Information

NPI Number:
1023586716
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60 W MAIN AVE STE 11A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORGAN HILL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95037-4553
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-484-7012
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 W MAIN AVE STE 11A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGAN HILL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95037-4553
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-484-7012
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/12/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PEREGRINO
Authorized Official First Name:
CAROLAIN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
408-484-7012

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1740639301 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".