Healthcare Provider Details

I. General information

NPI: 1619921657
Provider Name (Legal Business Name): 21ST CENTURY WELLNESS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23792 ROCKFIELD BLVD STE 100
LAKE FOREST CA
92630-2868
US

IV. Provider business mailing address

23792 ROCKFIELD BLVD STE 100
LAKE FOREST CA
92630-2868
US

V. Phone/Fax

Practice location:
  • Phone: 800-711-2062
  • Fax: 949-900-8268
Mailing address:
  • Phone: 800-711-2062
  • Fax: 949-900-8268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number300211AP
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. REBECCA BURGE COOPER
Title or Position: CEO
Credential: MFT
Phone: 800-711-2062