Provider Demographics
NPI:1659750974
Name:SO CAL OUTPATIENT
Entity Type:Organization
Organization Name:SO CAL OUTPATIENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:TIMANUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-381-0432
Mailing Address - Street 1:546 S CITRON ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-4420
Mailing Address - Country:US
Mailing Address - Phone:714-381-0432
Mailing Address - Fax:
Practice Address - Street 1:17671 IRVINE BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3178
Practice Address - Country:US
Practice Address - Phone:714-381-0432
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty