=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386529469
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEARTSTONE CA HEALTH PROVIDER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2025
-----------------------------------------------------
Last Update Date | 08/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3111 LOS FELIZ BLVD STE 210
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90039-1585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-425-0684
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3111 LOS FELIZ BLVD STE 210
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90039-1585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-425-0684
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | MR. NATHANIEL RANCE PENA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-927-9576
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------