MEDICARE: SOUTH OC WELLNESS

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	1041C0700X	Clinical Social Worker	LCS21316	CA

General Provider Information

NPI Number	:	1932328093
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH OC WELLNESS

Provider Business Mailing Address
First Line	:	2730 CAMINO CAPISTRANO
Second Line	:	SUITE 3
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92672
Country	:	US
Telephone Number	:	949-709-7000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2730 CAMINO CAPISTRANO
Second Line	:	SUITE 3
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92672-4847
Country	:	US
Telephone Number	:	949-709-7000
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MARLA STONE
Credential	:	LCSW
Telephone Number	:	949-709-7000

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	07/25/2008

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Directions to “SOUTH OC WELLNESS ” Practice Location

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