Provider Demographics
NPI:1285951871
Name:SOUTHERN CALIFORNIA PSYCHIATRIC GROUP, INC
Entity type:Organization
Organization Name:SOUTHERN CALIFORNIA PSYCHIATRIC GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BHUVANESWARI
Authorized Official - Middle Name:
Authorized Official - Last Name:NALLAMOTHU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-893-8838
Mailing Address - Street 1:28125 BRADLEY RD STE 220
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92586-2288
Mailing Address - Country:US
Mailing Address - Phone:951-309-2140
Mailing Address - Fax:951-309-2141
Practice Address - Street 1:28125 BRADLEY RD STE 220
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586
Practice Address - Country:US
Practice Address - Phone:951-309-2140
Practice Address - Fax:951-309-2141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2020-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 1041C0700X, 106H00000X, 2084P0804X
CAA898522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A898520Medicare UPIN