Healthcare Provider Details

I. General information

NPI: 1871660126
Provider Name (Legal Business Name): REIMAGINE NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 04/03/2021
Certification Date: 04/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 CALLE FRONTERA
SAN CLEMENTE CA
92673-5645
US

IV. Provider business mailing address

2021 CALLE FRONTERA
SAN CLEMENTE CA
92673-5645
US

V. Phone/Fax

Practice location:
  • Phone: 949-498-7671
  • Fax: 949-361-3361
Mailing address:
  • Phone: 949-498-7671
  • Fax: 949-361-3361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number060000022
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number060000022
License Number StateCA

VIII. Authorized Official

Name: MR. CHRISTIAN ERIC ERLENBUSH
Title or Position: SENIOR DIRECTOR - CLINICAL SERVICES
Credential: LCSW
Phone: 949-498-7671