=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417425604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAGEBRUSH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2018
-----------------------------------------------------
Last Update Date | 01/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 N GOLDEN CIRCLE DR STE A
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92705-3977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-778-1772
-----------------------------------------------------
Fax | 714-699-4984
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20500 BELSHAW AVENUE DPT 2034
-----------------------------------------------------
City | CARSON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90746-3506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-298-9228
-----------------------------------------------------
Fax | 714-699-4984
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL COUNSEL
-----------------------------------------------------
Name | AARON BAILEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-298-9228
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------