Provider Demographics
NPI:1083749238
Name:REIMAGINE NETWORK
Entity Type:Organization
Organization Name:REIMAGINE NETWORK
Other - Org Name:REIMAGINE NETWORK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OF SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:SOFIA
Authorized Official - Middle Name:CELESTINA
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:714-680-6060
Mailing Address - Street 1:130 LAGUNA RD
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3614
Mailing Address - Country:US
Mailing Address - Phone:714-680-6060
Mailing Address - Fax:714-633-7400
Practice Address - Street 1:130 LAGUNA RD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3614
Practice Address - Country:US
Practice Address - Phone:714-680-6060
Practice Address - Fax:714-633-7400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2021-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261Q00000X251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAADU70114FMedicaid