=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265974018
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE EDGE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2016
-----------------------------------------------------
Last Update Date | 07/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 525 CABRILLO PARK DR STE 100
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-778-1772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1217 LINDA LN
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92831-2001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-200-0491
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | VERONICA OCON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-200-0491
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 300669AP
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------