Provider Demographics
NPI:1215670542
Name:THE FORUM AT SAN DIEGO BRAINWORKS, INC.
Entity type:Organization
Organization Name:THE FORUM AT SAN DIEGO BRAINWORKS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUZMEYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-924-6442
Mailing Address - Street 1:5820 OBERLIN DR STE 203
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3744
Mailing Address - Country:US
Mailing Address - Phone:858-247-3162
Mailing Address - Fax:
Practice Address - Street 1:5820 OBERLIN DR STE 203
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3744
Practice Address - Country:US
Practice Address - Phone:858-247-3162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children