Healthcare Provider Details

I. General information

NPI: 1124873013
Provider Name (Legal Business Name): TD & SJC WELLNESS SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2024
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17150 NEWHOPE ST STE 208
FOUNTAIN VALLEY CA
92708-4250
US

IV. Provider business mailing address

17150 NEWHOPE ST STE 208
FOUNTAIN VALLEY CA
92708-4250
US

V. Phone/Fax

Practice location:
  • Phone: 253-686-2854
  • Fax:
Mailing address:
  • Phone: 253-686-2854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN CARMEL
Title or Position: OWNER
Credential:
Phone: 253-686-2854