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General NPI Number Information
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NPI Number | 1255195996
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Entity Type | Organization
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Legal Business Name | STEP UP ON SECOND STREET, INC.
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Dates
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Enumeration Date | 02/13/2024
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Last Update Date | 02/13/2024
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Provider Practice Location Address
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Address Line | 3314 W 1ST ST STE B
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City | SANTA ANA
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State | CA
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Zip | 92703-5449
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Country | US
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Telephone | 714-296-9361
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Fax |
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Provider Business Mailing Address
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Address Line | 3314 W 1ST ST STE B
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City | SANTA ANA
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State | CA
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Zip | 92703-5449
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Country | US
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Telephone | 714-296-9361
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Fax |
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Authorized Official
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Title or Position | CHIEF PROGRAM OFFICE
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Name | DAVID MARK TAVLIN
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Credential |
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Telephone | 310-985-5250
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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