Healthcare Provider Details

I. General information

NPI: 1346934247
Provider Name (Legal Business Name): BUENA PARK REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 W COMMONWEALTH AVE STE 215
FULLERTON CA
92832-1752
US

IV. Provider business mailing address

515 W COMMONWEALTH AVE STE 215
FULLERTON CA
92832-1752
US

V. Phone/Fax

Practice location:
  • Phone: 310-343-8684
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARIAM GOLDBERG
Title or Position: MANAGER
Credential:
Phone: 310-343-8684