Healthcare Provider Details

I. General information

NPI: 1215685292
Provider Name (Legal Business Name): MIND OC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18650 MACARTHUR BLVD STE 350
IRVINE CA
92612-1205
US

IV. Provider business mailing address

18650 MACARTHUR BLVD STE 350
IRVINE CA
92612-1205
US

V. Phone/Fax

Practice location:
  • Phone: 949-400-4157
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VICTOR STANLEY JORDAN
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 508-340-6228