Healthcare Provider Details

I. General information

NPI: 1992557185
Provider Name (Legal Business Name): AVENTURINE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8780 WARNER AVE STE 11
FOUNTAIN VALLEY CA
92708-3210
US

IV. Provider business mailing address

6226 E SPRING ST STE 275
LONG BEACH CA
90815-1455
US

V. Phone/Fax

Practice location:
  • Phone: 928-245-2940
  • Fax:
Mailing address:
  • Phone: 928-245-2940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SARAH BURNETT
Title or Position: OWNER
Credential:
Phone: 928-245-2940