Healthcare Provider Details

I. General information

NPI: 1144717778
Provider Name (Legal Business Name): SHARE OUR SELVES CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 SUPERIOR AVE
COSTA MESA CA
92627-3653
US

IV. Provider business mailing address

PO BOX 10159
COSTA MESA CA
92627-0050
US

V. Phone/Fax

Practice location:
  • Phone: 949-270-2135
  • Fax:
Mailing address:
  • Phone: 949-270-2135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CHRISTY WARD
Title or Position: CEO
Credential:
Phone: 949-536-3927