1649520982 NPI number — PACE RECOVERY CENTER, LLC

Table of content: (NPI 1649520982)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649520982 NPI number — PACE RECOVERY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACE RECOVERY CENTER, 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:
Provider Other Organization Name Type Code:
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:
1649520982
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20051 SW BIRCH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92660-1708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-390-5017
Provider Business Mailing Address Fax Number:
949-490-4053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 22ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTINGTON BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92648-3909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-274-9239
Provider Business Practice Location Address Fax Number:
714-274-9297
Provider Enumeration Date:
09/13/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SUZMEYAN
Authorized Official First Name:
SHAHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CCO
Authorized Official Telephone Number:
213-924-6442

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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