Healthcare Provider Details

I. General information

NPI: 1760803746
Provider Name (Legal Business Name): WEST COAST HEALTHY LIVING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2013
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2158 PACIFIC AVE
LONG BEACH CA
90806-4514
US

IV. Provider business mailing address

2158 PACIFIC AVE
LONG BEACH CA
90806-4514
US

V. Phone/Fax

Practice location:
  • Phone: 951-567-6051
  • Fax:
Mailing address:
  • Phone: 951-567-6051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name: KUAWANNA THOMPSON
Title or Position: ADMINISTRATION
Credential:
Phone: 951-567-6051