Healthcare Provider Details

I. General information

NPI: 1316794183
Provider Name (Legal Business Name): STANDUP FOR KIDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2024
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 EL CAMINO DR STE E
COSTA MESA CA
92626-5545
US

IV. Provider business mailing address

PO BOX 14398
IRVINE CA
92623-4398
US

V. Phone/Fax

Practice location:
  • Phone: 714-356-5437
  • Fax:
Mailing address:
  • Phone: 714-356-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number State

VIII. Authorized Official

Name: CARLIA OLDFATHER
Title or Position: DIR. OF BUSINESS & PROGRAM OPS.
Credential:
Phone: 260-232-2769