Healthcare Provider Details

I. General information

NPI: 1871320713
Provider Name (Legal Business Name): NIKOLAI BREMER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 E FRUIT ST
SANTA ANA CA
92701-4206
US

IV. Provider business mailing address

47 SPARROWHAWK
IRVINE CA
92604-3225
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-9373
  • Fax:
Mailing address:
  • Phone: 949-278-3784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCI45281124
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: