Healthcare Provider Details

I. General information

NPI: 1861159501
Provider Name (Legal Business Name): BEWELL ORANGE COUNTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2021
Last Update Date: 11/17/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24621 AQUILLA DR
DANA POINT CA
92629-1042
US

IV. Provider business mailing address

27130 PASEO ESPADA STE A1423
SAN JUAN CAPISTRANO CA
92675-6712
US

V. Phone/Fax

Practice location:
  • Phone: 949-529-5945
  • Fax:
Mailing address:
  • Phone: 949-529-5945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: BROOKE ZIMMERMAN
Title or Position: VP OF REVENUE CYCLE
Credential:
Phone: 217-649-5309