Provider Demographics
NPI:1538908074
Name:MONTCLAIR PSYCHIATRY AND INTERNAL MEDICINE INC
Entity type:Organization
Organization Name:MONTCLAIR PSYCHIATRY AND INTERNAL MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENOYE
Authorized Official - Middle Name:R
Authorized Official - Last Name:UKU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-660-2111
Mailing Address - Street 1:9655 MONTE VISTA AVE STE 402A
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-2238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9655 MONTE VISTA AVE STE 402A
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2238
Practice Address - Country:US
Practice Address - Phone:909-732-7641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty