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General NPI Number Information
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NPI Number | 1528650686
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Entity Type | Organization
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Legal Business Name | OC TEEN CENTER LLC
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Dates
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Enumeration Date | 02/09/2021
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Last Update Date | 03/07/2024
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Provider Practice Location Address
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Address Line | 3188 AIRWAY AVE STE L
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City | COSTA MESA
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State | CA
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Zip | 92626-4652
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Country | US
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Telephone | 800-478-0233
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Fax |
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Provider Business Mailing Address
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Address Line | 3188 AIRWAY AVE STE L
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City | COSTA MESA
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State | CA
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Zip | 92626-4652
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | JONAH BAUTISTA
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Credential |
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Telephone | 714-716-5044
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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