=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699220236
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVISION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2016
-----------------------------------------------------
Last Update Date | 08/24/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 136 S IMPERIAL HWY
-----------------------------------------------------
City | ANAHEIM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92807-3943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-602-8855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 136 S IMPERIAL HWY
-----------------------------------------------------
City | ANAHEIM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92807-3943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-602-8855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE CHAIR, BOARD OF DIRECTORS
-----------------------------------------------------
Name | MR. JAMES FRANK SANDO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-206-7754
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------