Healthcare Provider Details

I. General information

NPI: 1609567593
Provider Name (Legal Business Name): STORMBREAKER WELLNESS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2023
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11801 PIERCE ST STE 200
RIVERSIDE CA
92505-4400
US

IV. Provider business mailing address

11801 PIERCE ST STE 200
RIVERSIDE CA
92505-4400
US

V. Phone/Fax

Practice location:
  • Phone: 951-836-9444
  • Fax: 951-848-0797
Mailing address:
  • Phone: 951-836-9444
  • Fax: 951-848-0797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. ANTHONY GARY RAMIREZ
Title or Position: CEO, TREASURER
Credential: MSW, LCSW
Phone: 909-270-6478