1689156507 NPI number — LEAD RECOVERY TRANSITIONAL LIVING CENTER, LLC

Table of content: (NPI 1689156507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689156507 NPI number — LEAD RECOVERY TRANSITIONAL LIVING CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEAD RECOVERY TRANSITIONAL LIVING 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:
LEAD RECOVERY CENTER
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:
1689156507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1516 BROOKHOLLOW DR UNIT A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92705-5401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-282-9447
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1516 BROOKHOLLOW DR UNIT A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92705-5401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-282-9447
Provider Business Practice Location Address Fax Number:
949-666-8393
Provider Enumeration Date:
09/06/2018

Additional Information

Authorized Official

Authorized Official Last Name:
NURMBERG
Authorized Official First Name:
KATHRYN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
949-282-9447

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 276400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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