=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609567593
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STORMBREAKER WELLNESS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2023
-----------------------------------------------------
Last Update Date | 12/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11801 PIERCE ST STE 200
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92505-4400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-836-9444
-----------------------------------------------------
Fax | 951-848-0797
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11801 PIERCE ST STE 200
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92505-4400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-836-9444
-----------------------------------------------------
Fax | 951-848-0797
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO, TREASURER
-----------------------------------------------------
Name | MR. ANTHONY GARY RAMIREZ
-----------------------------------------------------
Credential | MSW, LCSW
-----------------------------------------------------
Telephone | 909-270-6478
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------