Provider Demographics
NPI:1619921657
Name:21ST CENTURY WELLNESS, INC
Entity Type:Organization
Organization Name:21ST CENTURY WELLNESS, INC
Other - Org Name:REBECCA'S HOUSE EATING DISORDER TREATMENT PROGRAMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:BURGE
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:800-711-2062
Mailing Address - Street 1:23792 ROCKFIELD BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2868
Mailing Address - Country:US
Mailing Address - Phone:800-711-2062
Mailing Address - Fax:949-900-8268
Practice Address - Street 1:23792 ROCKFIELD BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2868
Practice Address - Country:US
Practice Address - Phone:800-711-2062
Practice Address - Fax:949-900-8268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0850X
CA300211AP261QR0405X
CA910223133V00000X
CA15610103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1619921657Other21ST CENTURY WELLNESS, INC