=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235900945
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RISEN WARRIORS FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2024
-----------------------------------------------------
Last Update Date | 01/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16B JOURNEY
-----------------------------------------------------
City | ALISO VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92656-3317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-309-6681
-----------------------------------------------------
Fax | 949-340-8399
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 SABLE
-----------------------------------------------------
City | RANCHO SANTA MARGARITA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92688-5571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-309-6681
-----------------------------------------------------
Fax | 949-340-8399
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/CEO
-----------------------------------------------------
Name | MR. ROBERT BUCHANAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-309-6681
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------