1164873253 NPI number — IRECOVERY BEHAVIORAL HEALTH CLINIC, LLC

Table of content: (NPI 1164873253)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164873253 NPI number — IRECOVERY BEHAVIORAL HEALTH CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IRECOVERY BEHAVIORAL HEALTH CLINIC, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
IRECOVERY SANTA MARIA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164873253
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
68778 E PALM CANYON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CATHEDRAL CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92234-1313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-631-5268
Provider Business Mailing Address Fax Number:
805-631-5264

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
607 PLAZA DR
Provider Second Line Business Practice Location Address:
SUITE C-102
Provider Business Practice Location Address City Name:
SANTA MARIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93454-6944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-631-5268
Provider Business Practice Location Address Fax Number:
805-631-5264
Provider Enumeration Date:
06/29/2016

Additional Information

Authorized Official

Authorized Official Last Name:
KROLL
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
SUPERVISOR
Authorized Official Telephone Number:
805-631-5268

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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