Healthcare Provider Details

I. General information

NPI: 1518478643
Provider Name (Legal Business Name): EB PSYCH SOLUTION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2017
Last Update Date: 11/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 E 17TH ST
SANTA ANA CA
92701-2201
US

IV. Provider business mailing address

1125 E 17TH ST N354
SANTA ANA CA
92701-2201
US

V. Phone/Fax

Practice location:
  • Phone: 714-875-3443
  • Fax: 714-948-8248
Mailing address:
  • Phone: 714-875-3443
  • Fax: 714-948-8248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry
License NumberA63633
License Number StateCA

VIII. Authorized Official

Name: ENRICO BALCOS
Title or Position: PRESIDENT
Credential: MD
Phone: 714-875-3443