MEDICARE: ROOARK MENTAL HEALTH & WELLNESS A PHYSICIAN ASSISTANT CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1770439788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROOARK MENTAL HEALTH & WELLNESS A PHYSICIAN ASSISTANT CORPORATION

Provider Business Mailing Address
First Line	:	502 EUCLID AVE STE 202
Second Line	:
City	:	NATIONAL CITY
State	:	CA
Zip	:	91950-2985
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	502 EUCLID AVE STE 202
Second Line	:
City	:	NATIONAL CITY
State	:	CA
Zip	:	91950-2985
Country	:	US
Telephone Number	:	707-684-0740
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	EKAETE UDOH
Credential	:	PA
Telephone Number	:	707-684-0740

Provider Enumeration Date	:	03/10/2026
Last Update Date	:	03/10/2026

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