Provider Demographics
NPI:1306072426
Name:INTEGRATED MIND INSTITUTE
Entity type:Organization
Organization Name:INTEGRATED MIND INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WARRIS
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:WALAYAT
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:909-796-4774
Mailing Address - Street 1:24550 LAWTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3336
Mailing Address - Country:US
Mailing Address - Phone:909-796-4774
Mailing Address - Fax:909-796-2774
Practice Address - Street 1:24949 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2811
Practice Address - Country:US
Practice Address - Phone:909-796-4774
Practice Address - Fax:909-796-2774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-03
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA970802084P0800X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A970800Medicaid
CA00A970800Medicaid
CA00A970800Medicare PIN