Healthcare Provider Details

I. General information

NPI: 1215670542
Provider Name (Legal Business Name): THE FORUM AT SAN DIEGO BRAINWORKS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 OBERLIN DR STE 203
SAN DIEGO CA
92121-3744
US

IV. Provider business mailing address

5820 OBERLIN DR STE 203
SAN DIEGO CA
92121-3744
US

V. Phone/Fax

Practice location:
  • Phone: 858-247-3162
  • Fax:
Mailing address:
  • Phone: 858-247-3162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. SHAHAN SUZMEYAN
Title or Position: COMPLIANCE
Credential:
Phone: 213-924-6442