1114284817 NPI number — CARDINAL WELLNESS, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114284817 NPI number — CARDINAL WELLNESS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARDINAL WELLNESS, INC.
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:
Provider Other Organization Name Type Code:
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:
1114284817
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1875 S BASCOM AVE
Provider Second Line Business Mailing Address:
SUITE 2400
Provider Business Mailing Address City Name:
CAMPBELL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-529-7864
Provider Business Mailing Address Fax Number:
408-331-3211

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1875 S. BASCOM AVENUE
Provider Second Line Business Practice Location Address:
SUITE 2400
Provider Business Practice Location Address City Name:
CAMPBELL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95008-2356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-529-7864
Provider Business Practice Location Address Fax Number:
408-331-3211
Provider Enumeration Date:
04/18/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
AGREDANO DE MORENO
Authorized Official First Name:
YOLANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/PSYCHIATRIST
Authorized Official Telephone Number:
408-529-7864

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  A96450 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: A96450 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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