Healthcare Provider Details

I. General information

NPI: 1407786528
Provider Name (Legal Business Name): SOUTH ORANGE COUNTY WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27123 CALLE ARROYO STE 2121
SAN JUAN CAPISTRANO CA
92675-6785
US

IV. Provider business mailing address

27123 CALLE ARROYO STE 2121
SAN JUAN CAPISTRANO CA
92675-6785
US

V. Phone/Fax

Practice location:
  • Phone: 619-592-3558
  • Fax: 949-804-3072
Mailing address:
  • Phone: 619-592-3558
  • Fax: 949-804-3072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL WAYLAND JORDAN SR.
Title or Position: CEO
Credential:
Phone: 619-592-3558