MEDICARE: FORWARD WELLNESS , INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	102441	CA
2	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)	102441	CA

General Provider Information

NPI Number	:	1730688656
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORWARD WELLNESS , INC.

Provider Business Mailing Address
First Line	:	1041 E YORBA LINDA BLVD STE 202
Second Line	:
City	:	PLACENTIA
State	:	CA
Zip	:	92870-3760
Country	:	US
Telephone Number	:	800-701-0937
Fax Number	:	800-701-0937

Provider Business Practice Location Address
First Line	:	1041 E YORBA LINDA BLVD STE 202
Second Line	:
City	:	PLACENTIA
State	:	CA
Zip	:	92870-3760
Country	:	US
Telephone Number	:	800-701-0937
Fax Number	:	800-701-0937

Authorized Official
Title or Position	:	PROGRAM MANAGER
Name	:	JOSEPH CHAVEZ
Credential	:
Telephone Number	:	714-478-0501

Provider Enumeration Date	:	02/06/2018
Last Update Date	:	01/16/2019

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