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1720 W Ball Rd Ste 4c Anaheim CA 92804-5591 | |
| (626) 429-0088 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 1720 W Ball Rd Ste 4c, Anaheim, California |
| Authorized Official Name and Position | Jackson Tea (CFO) |
| Authorized Official Contact | 6264290088 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
532 N Magnolia Ave # 769 Anaheim CA 92801-4937 Ph: (626) 429-0088 | 1720 W Ball Rd Ste 4c Anaheim CA 92804-5591 Ph: (626) 429-0088 |
| NPI Number | 1780435628 |
|---|---|
| Provider Enumeration Date | 03/28/2024 |
| Last Update Date | 08/07/2024 |
| Certification Date | 08/07/2024 |
| Medicare PECOS PAC ID | 2062951205 |
|---|---|
| Medicare Enrollment ID | O20240830003581 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1780435628 | NPI | - | NPPES |
| Provider Name | Scott A Irwin |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1225117716 PECOS PAC ID: 1355305426 Enrollment ID: I20041117001265 |
| Provider Name | Medard Sison |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1922507037 PECOS PAC ID: 8820352057 Enrollment ID: I20180515002925 |
| Provider Name | Carlos Barrios |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1174643647 PECOS PAC ID: 8921188855 Enrollment ID: I20181220002882 |
| Provider Name | Clint Nacar |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1609466259 PECOS PAC ID: 1153738232 Enrollment ID: I20210408000601 |
| Provider Name | Dave P Ravi |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1043501364 PECOS PAC ID: 5890032601 Enrollment ID: I20211117001577 |
| Provider Name | Torri Leigh Montgomery |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1275928095 PECOS PAC ID: 3971977588 Enrollment ID: I20230322002503 |
| Provider Name | Cristian Cuevas |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1013796200 PECOS PAC ID: 5496292344 Enrollment ID: I20240808004072 |
| Provider Name | Griselda Hernandez |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1891377826 PECOS PAC ID: 6002354958 Enrollment ID: I20240809004023 |
| Provider Name | Shaheena Gazipura |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1174971048 PECOS PAC ID: 4981139060 Enrollment ID: I20241126002908 |
| Provider Name | Richard Gabriel Samedra |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1093561904 PECOS PAC ID: 2163957176 Enrollment ID: I20241127004205 |
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