Provider Demographics
NPI:1558448167
Name:CJ WELLNET INC
Entity Type:Organization
Organization Name:CJ WELLNET INC
Other - Org Name:WELLNET MEDI-VAN TRANSPORTATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:F
Authorized Official - Last Name:SPROWLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-337-1671
Mailing Address - Street 1:2021 E 4TH ST.
Mailing Address - Street 2:209
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3913
Mailing Address - Country:US
Mailing Address - Phone:714-665-6591
Mailing Address - Fax:714-632-8409
Practice Address - Street 1:2021 E 4TH ST.
Practice Address - Street 2:209
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3913
Practice Address - Country:US
Practice Address - Phone:714-665-6591
Practice Address - Fax:714-632-8409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMTN01188F343900000X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMTN01188FMedicaid
CAMTNX10007Medicaid