Provider Demographics
NPI:1871362186
Name:ANTEDAR PSYCHIATRIC NURSING PROFESSIONAL SERVICES, INC
Entity type:Organization
Organization Name:ANTEDAR PSYCHIATRIC NURSING PROFESSIONAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BARIASA
Authorized Official - Middle Name:
Authorized Official - Last Name:KANABOLO
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:951-236-9430
Mailing Address - Street 1:PO BOX 51927
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92517-2927
Mailing Address - Country:US
Mailing Address - Phone:951-236-9430
Mailing Address - Fax:
Practice Address - Street 1:6860 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3821
Practice Address - Country:US
Practice Address - Phone:951-236-9430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-28
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty