Provider Demographics
NPI:1790398170
Name:STILL WATER WELLNESS GROUP
Entity Type:Organization
Organization Name:STILL WATER WELLNESS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMATTINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-506-6983
Mailing Address - Street 1:34145 PACIFIC COAST HWY # 818
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-2808
Mailing Address - Country:US
Mailing Address - Phone:603-966-8389
Mailing Address - Fax:
Practice Address - Street 1:24101 BIG TIMBER ST
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2920
Practice Address - Country:US
Practice Address - Phone:603-966-8389
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-26
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Single Specialty