=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689463804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECTRUM OPTIMAL CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2025
-----------------------------------------------------
Last Update Date | 05/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 405 WILSHIRE PL
-----------------------------------------------------
City | BARSTOW
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92311-2928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-295-0388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 405 WILSHIRE PL
-----------------------------------------------------
City | BARSTOW
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92311-2928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-295-0388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BCBA - CLINICAL DIRECTOR
-----------------------------------------------------
Name | TAWANA PATRON
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 909-295-0388
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------