Healthcare Provider Details

I. General information

NPI: 1245833524
Provider Name (Legal Business Name): IAMPURPOSE WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 3RD ST STE 2
RIVERSIDE CA
92507-3454
US

IV. Provider business mailing address

1410 3RD ST STE 2
RIVERSIDE CA
92507-3454
US

V. Phone/Fax

Practice location:
  • Phone: 909-471-0697
  • Fax: 951-405-4476
Mailing address:
  • Phone: 909-471-0697
  • Fax: 951-405-4476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. DRETONA T. MADDOX
Title or Position: NURSE SOCIAL WORK PRACTITIONER
Credential: RN, PHN, LCSW
Phone: 909-471-0697