Healthcare Provider Details

I. General information

NPI: 1245035609
Provider Name (Legal Business Name): TURNING LEAF WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2025
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 NE SHALE CT
ROSEBURG OR
97470-5751
US

IV. Provider business mailing address

1706 NE SHALE CT
ROSEBURG OR
97470-5751
US

V. Phone/Fax

Practice location:
  • Phone: 559-978-0302
  • Fax:
Mailing address:
  • Phone: 559-978-0302
  • Fax:

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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: RONALD BUSTAMANTE
Title or Position: CO-OWNER
Credential: CSWA
Phone: 559-978-0302