1740727932 NPI number — BE WELL COLLABORATIVE CARE CENTER

Table of content: (NPI 1740727932)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740727932 NPI number — BE WELL COLLABORATIVE CARE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BE WELL COLLABORATIVE CARE CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BE WELL COLLABORATIVE CARE OF ALISO VIEJO
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740727932
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24541 PACIFIC PARK DR
Provider Second Line Business Mailing Address:
SUITE 109
Provider Business Mailing Address City Name:
ALISO VIEJO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92656-3065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-427-0999
Provider Business Mailing Address Fax Number:
949-446-0585

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24541 PACIFIC PARK DR
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
ALISO VIEJO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92656-3065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-427-0999
Provider Business Practice Location Address Fax Number:
949-446-0585
Provider Enumeration Date:
01/25/2017

Additional Information

Authorized Official

Authorized Official Last Name:
KOHLI
Authorized Official First Name:
SANJIVAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
949-373-6288

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RS0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RS0012X , with the licence number: A109968 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207YS0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0006X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080S0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084S0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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