Provider Demographics
NPI:1326415613
Name:WEST COAST WELLNESS CENTERS LLC
Entity Type:Organization
Organization Name:WEST COAST WELLNESS CENTERS LLC
Other - Org Name:WELLNESS COUNSELING VIDA ENTERA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-266-7682
Mailing Address - Street 1:31631 AUTO CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-4523
Mailing Address - Country:US
Mailing Address - Phone:623-388-3353
Mailing Address - Fax:
Practice Address - Street 1:31631 AUTO CENTER DR
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4523
Practice Address - Country:US
Practice Address - Phone:623-388-3353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOCAL ADDICTION & TREATMENT COMPANY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-21
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA330133AP324500000X
CA330133DP324500000X
CA330133BP324500000X
CA330133CP324500000X
CA330133FP324500000X
CA330133GP324500000X
CA330133HP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility