Provider Demographics
NPI:1871953745
Name:SHARE OUR SELVES
Entity type:Organization
Organization Name:SHARE OUR SELVES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-270-2132
Mailing Address - Street 1:1550 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3653
Mailing Address - Country:US
Mailing Address - Phone:949-270-2132
Mailing Address - Fax:
Practice Address - Street 1:1014 N BROADWAY
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-3408
Practice Address - Country:US
Practice Address - Phone:949-270-2132
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1508073685Medicaid