Provider Demographics
NPI:1023598299
Name:SOCAL ADOLESCENT WELLNESS, INC.
Entity type:Organization
Organization Name:SOCAL ADOLESCENT WELLNESS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COOWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:SEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-240-8989
Mailing Address - Street 1:7641 TALBERT AVE STE 215
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-8617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16052 BEACH BLVD STE 135
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-3817
Practice Address - Country:US
Practice Address - Phone:402-250-8989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOCAL ADOLESCENT WELLNESS, LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health