Basic Information
| Provider Information | |||||||||
| NPI: | 1518287028 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI-CITY MENTAL HEALTH AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TRI CITY MENTAL HEALTH AUTHORITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 N INDIAN HILL BLVD | ||||||||
| Address2: | UNIT B | ||||||||
| City: | CLAREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917112788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097843250 | ||||||||
| FaxNumber: | 9096234073 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 ROYALTY DR | ||||||||
| Address2: | SUITES 160,170,180,205,280 & 290 | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097843200 | ||||||||
| FaxNumber: | 9098650730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2010 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | MAJORS | ||||||||
| AuthorizedOfficialFirstName: | NATALIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9096236131 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | W1208 | 01 | CA | MEDICARE PROVIDER TRANSACTION ACCESS NUMBER | OTHER |