Basic Information
| Provider Information | |||||||||
| NPI: | 1821456906 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WINTERS | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BT | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9110 SW 38TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972195367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037844431 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11037 WARNER AVE | ||||||||
| Address2: | #339 | ||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927084007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002734292 | ||||||||
| FaxNumber: | 9492534627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2016 | ||||||||
| LastUpdateDate: | 03/09/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.