Provider Demographics
NPI:1679338578
Name:COMMUNITY WELL CALIFORNIA
Entity type:Organization
Organization Name:COMMUNITY WELL CALIFORNIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:R
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:COMMUNITY HEALTH
Authorized Official - Phone:909-419-9278
Mailing Address - Street 1:626 W LANCASTER BLVD # 61
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-3108
Mailing Address - Country:US
Mailing Address - Phone:909-419-9278
Mailing Address - Fax:
Practice Address - Street 1:626 W LANCASTER BLVD # 61
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3108
Practice Address - Country:US
Practice Address - Phone:909-990-1155
Practice Address - Fax:424-361-7766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-19
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage