Healthcare Provider Details

I. General information

NPI: 1699938902
Provider Name (Legal Business Name): WAYMAKERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16580 HARBOR BLVD UNIT M
FOUNTAIN VALLEY CA
92708
US

IV. Provider business mailing address

440 EXCHANGE STE 250
IRVINE CA
92602-1390
US

V. Phone/Fax

Practice location:
  • Phone: 714-975-5201
  • Fax:
Mailing address:
  • Phone: 949-250-0488
  • Fax: 714-540-1908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: RONNETTA JOHNSON
Title or Position: EXECUTIVE DIRECTOR
Credential: MA
Phone: 949-250-0488