Healthcare Provider Details

I. General information

NPI: 1831722206
Provider Name (Legal Business Name): THERAWIDE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2020
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

591 COLLINS DR APT 6
MERCED CA
95348-3178
US

IV. Provider business mailing address

591 COLLINS DR APT 6
MERCED CA
95348-3178
US

V. Phone/Fax

Practice location:
  • Phone: 310-307-9114
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: BRANDON HIGHTOWER
Title or Position: CEO/DIRECTOR OF OPERATIONS
Credential:
Phone: 310-307-9114