Provider Demographics
NPI:1053776484
Name:PUBLIC GUARDIAN
Entity type:Organization
Organization Name:PUBLIC GUARDIAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY PUBLIC GUARDIAN
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:PEAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-955-1540
Mailing Address - Street 1:3625 14TH ST.
Mailing Address - Street 2:P.O. BOX 1405
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92502
Mailing Address - Country:US
Mailing Address - Phone:951-955-1540
Mailing Address - Fax:951-955-1610
Practice Address - Street 1:3625 14TH ST.
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501
Practice Address - Country:US
Practice Address - Phone:951-955-1540
Practice Address - Fax:951-955-1610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherPUBLIC GUARDIAN