=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457982720
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFELINE 2 WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2020
-----------------------------------------------------
Last Update Date | 01/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 DOVE ST STE 299
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-3036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-497-3307
-----------------------------------------------------
Fax | 714-464-4478
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 436 E RAINIER AVE
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92865-1114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-319-7208
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. JACQUELINE D BREDEHOFT
-----------------------------------------------------
Credential | MSN, PMHNP-BC
-----------------------------------------------------
Telephone | 714-497-3307
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------