Healthcare Provider Details

I. General information

NPI: 1265698500
Provider Name (Legal Business Name): BRENT ANTHONY BARCELLONA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2008
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16580 HARBOR BLVD STE M
FOUNTAIN VALLEY CA
92708-1385
US

IV. Provider business mailing address

16580 HARBOR BLVD STE M
FOUNTAIN VALLEY CA
92708-1385
US

V. Phone/Fax

Practice location:
  • Phone: 949-250-0488
  • Fax: 714-659-6379
Mailing address:
  • Phone: 949-250-0488
  • Fax: 714-659-6379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number107180
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: