Organization
SHARE OUR SELVES
Active
Other names
SOS
Organization subpart
No
Provider details
NPI number
Authorized official
KATHLEEN BRUSKI (CREDENTIALING MANAGER)
(949) 270-2132
Entity
Organization
Contact information
Practice address
1014 N BROADWAY, SANTA ANA, CA 92701-3408
(949) 270-2132
Mailing address
1550 SUPERIOR AVE, COSTA MESA, CA 92627-3653
(949) 270-2132
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1508073685
—
CA
Enumeration date
03/04/2016
Last updated
03/04/2016
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